Transformation Team

What does the team do?

The Transformation Team was set up in 2014, with the aim of coordinating, expanding and improving the provision of care to the more frail and vulnerable patients in our communities. The team is led by an experienced local district nurse and includes a pharmacist, physiotherapist and former social workers in addition to the nursing staff. Together, the Transformation Team conduct a holistic review of patients and their carers, taking into account medical, social and care needs. Working closely with local volunteer and health agencies the Transformation Team help put in place packages to help care for our vulnerable patients and maintain independence as much as is possible. Patients are referred from General Practice, Community Teams and also from our local hospitals. The Team work closely with Community Elderly Care Consultants to support their clinical expertise and also with discharge teams in the hospitals where required to ensure that patients are supported at home after leaving hospital. Looking to the future, TLC and its Transformation Team are developing an Acute Frailty Service for our area in collaboration with other stakeholders, West Hampshire CCG and Southern Health Foundation Trust.

 

Who is in the team?

Pip (Team Lead)

An experienced Community Nurse and Nurse Prescriber. Pip is responsible for team management, clinical supervision, triage, and holistic assessments. Pip has also been involved with the Frailty Clinic in Chandlers Ford.

Jilly (Senior Nurse)

Another experienced Community Nurse. Jilly is the Romsey and North Baddesley PCN lead and her responsibilities are triage, patient allocation, team support and holistic assessments. Jilly has also been involved with the Frailty clinic.

Camelia (Pharmacist)

With a background of Community Pharmacy, Camelia conducts medication reviews for housebound patients, increasing understanding of medication and helping to deprescribe medications no longer required. Camelia also supports the Team with pharmacy matters and holistic assessments as well as supporting the Frailty clinic.

Lesley (Physiotherapist)

As an experienced Community Physiotherapist Lesley is responsible for mobility and falls assessments and advises the Team on equipment. In addition Lesley can conduct holistic assessments and annual housebound COPD reviews.

Christine (Social Practitioner)

Christine is the Chandlers Ford PCN lead and with her background as a Community Social Worker she is responsible for supporting the Team in social care issues and conducts holistic assessments as well as specific social care needs reviews.

Sue R (Nurse)

Sue is a Community Nurse who is also the Eastleigh PCN lead. As well as conducting holistic assessments Sue leads the Eastleigh complex wound clinic.

Mandy (Health Care Assistant)

Mandy provides physiotherapy support, frailty assessments and annual housebound Diabetic reviews as well as supporting the Eastleigh complex wound clinic.

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