LINC is an integrated multi-disciplinary service, jointly funded and staffed by Lewisham and Greenwich NHS Trust and London Borough of Lewisham, which proves rehabilitation and support to adult Lewisham residents to return them to an optimum level of function after an admission to hospital or a decline in function in the community.
We work with people who live in Lewisham, who are 18 or older – although the average age of people served is 80 – who need some physical rehabilitation either after being in hospital or because they are not coping so well in the community. We serve over 3,000 people per year.
Staff are based in multi-disciplinary clusters which provide a service to Lewisham residents in their own homes and in 22 Nursing Home beds, based in Brymore Nursing Home in Grove Park.
There are two directions of patient flow:
1. Supported discharge, which enables patients to be discharged safely and efficiently from hospital back to their own homes, or to Brymore nursing home beds on a step-down basis and
2. Admission avoidance which provides a Rapid Response to LAS, A&E and community-based referrals for patients in their own home to prevent admission to hospital, or to admit them briefly to the same nursing home beds on a step-up basis.
The supported discharge service may be for you if:
- You are a Lewisham resident
- You are 18 or over ( 55 or over if going into a Brymore bed)
- You are likely to improve significantly in 6 weeks or less
- Can transfer without hoist (bed-based) or with help of carer (home)
- Can follow and remember simple instructions
- If you are living alone, you must be safe at home overnight and for periods during the day
- Willing to be treated by LINC and if carer is involved, they are willing to have person treated by LINC
- Requires rehabilitation input from two or more disciplines from the team
Patients referred for admission avoidance should be:
- Lewisham resident, 18 years and over (55 yrs and over for bed based)
- In need of short-term intervention which will prevent unnecessary admission to Acute hospital or long-term care
- Needs cannot be met routinely by mainstream district nursing, community therapy or social care
The multi-disciplinary clusters are made up of nurses, social workers, physiotherapists, occupational therapist and support workers, together with business support. In addition, there is support from the Care of the Elderly Consultant Team at UHL and additional arrangements for speech therapy input as appropriate.
The nurses in LINC will help with medication reviews, monitor skin breakdown, help with incontinence issues, check pain management and work closely with the GP to support you becoming more independent.
Physiotherapists will give you individual exercise programmes to help you move from one place to another, become stronger, less likely to fall, be more active and suggest and provide equipment, walking aides and other device to support your mobility.
Occupational therapists will help you with activities that allow you to be more independent in washing, dressing, toileting, cooking, improve your memory, attention and problem solving, work leisure and education.
Social workers will help you, your family and carers to deal with changes in your life, help you to organise paid carers to support you at home, make sure that you are safe and your needs are met appropriately and advise you about local resources.
Our support workers will visit you daily to help with your personal care and support you in doing the exercises and task suggested personally for you by the professional staff mentioned above.
Referrals are processed through a Central Point of Referral and service is provided free at the point of service for up to 6 weeks according to need. The service is available 7 days per week from 8am to 8pm and referring GP’s can speak directly to a member of the multi-disciplinary team at any time during these hours via mobile number :07799 711424. We are an agreed pathway for the London Ambulance Service ( LAS). LAS referrals are taken directly and responded to within 2-4 hours, often much faster’.
We will come to see you in your own home, help you to arrange your discharge home from hospital or, if you are living at home but something has changed in how you are coping , then we will work together with you to see if we can prevent you having to go to hospital unless you really need to do so.
Where are we based?
Our Clinical Assessment Service (CAS) is based at University Hospital Lewisham, and is supported by Dr Liz Aitken, Consultant, who will help assess your needs and see if we can quickly and safely return you back to your own home with any necessary additional support. Admission Avoidance nurses, social workers and therapists will see you in A&E 7 days per week up to 10 pm at night and if required can visit your home to make sure you are safe.
Our Community Rapid Response Team (CRRT) based at Marvels Lane, Grove Park will continue this admission avoidance activity by responding rapidly to London Ambulance Service calls and visiting you at home, providing equipment, support and therapy according to your individual needs.
Our Supported Discharge Team, based in Ivy House, Catford will visit you in hospital to assess your needs, help to arrange your discharge home and visit you on a planned basis to help you meet agreed rehabilitation goals.
And finally, if the plan is that you are going to continue to be at home, but we cannot safely support you at home until you are more independent, then you can stay in one of our 22 beds in Brymore Nursing home, Grove Park for a short stay until you are able to go home again. This is usually up to 5 weeks if you are coming from hospital, or 3 weeks if you are coming from the community.
LINC provide every discharged patient with an anonymous customer satisfaction survey to complete, and these score consistently at 80% or above in the “satisfied” or “very satisfied” range.