HNY Policy and Pathway Repository - York
Community Services
General contact numbers
District Nurse Contact Details
Community Heart Failure Team (new referral process) - only available via an N3 connection
Community Response Team Information
Community Therapy Team Information - Nov 23
York Integrated Care Team (YICT) - 01904 721849 / 721537
- First Choice for all City of York practices
- Hours of service Telephone access 8.30am – 6pm Monday to Friday
- Service user information leaflet
North Integrated Care Team (NICT) - 01904 724827 or GP surgery of patient concerned
- First Choice for Millfield, Stillington, Tollerton, Helmsley and Pickering GP practices
Exercise and wellness
Mental Health
Tier 3 Obesity Management Service
Local Authorities' Exercise Programmes and Referrals
- City of York Council - 'Better - Healthwise: Physical Activity GP Referral Scheme' / CYC Health Trainers
- North Yorkshire Council - Healthy You
- Selby - Healthy Weight Support
Children and Young People
North Yorkshire
YorSexualHealth
Alcohol and drugs
CITY OF YORKPrimary Care Networks and York Drug and Alcohol Service Standard Operating Protocol For information about treatment and support available around alcohol and drug use in York see:
York Drug and Alcohol ServiceYork Drug and Alcohol Service is run by specialists from Change Grow Live (CGL) and Emerging Futures and funded by City of York Council. They provide support for people dealing with issues related to drugs and/or alcohol. Support is free and confidential, and the range of support includes:
Self-referrals are very welcome, as are referrals from professionals To refer / for more information: The Gate – for children and young peopleThe Gate York offers a range of support for children and young people up to 25 years affected by their own or someone else’s substance use. Their aim is to provide young people with the knowledge, skills, and confidence to identify and appropriately respond to risks associated with substance use. Self-referrals and referrals from professionals are both welcome. To refer / for more information: New WaysThe New Ways team is on hand to support patients who want support to make changes around how much alcohol they’re drinking but don’t need treatment for physical dependence to alcohol. New Ways is run by Change Grow Live (CGL) and funded by City of York Council. New Ways work closely with the CYC Health Trainers who can also help people with reducing alcohol; you can refer to either team and they will work out who is best placed to help. To refer / for more information online referral form (hosted by York Drug and Alcohol Service) Self-referrals and referrals from professionals are both welcome. |
NORTH YORKSHIRENorth Yorkshire Horizons (Adults) and North Yorkshire Rise (Young People) - run by HumanKindNorth Yorkshire Horizons (specialist service for adults wanting to be free from drugs or alcohol misuse) and North Yorkshire Rise (specialist service for young people aged 10-19, or 24 with SEND) have a single point of contact: 01723 330730 / freephone 08000 141480. Website: www.nyhorizons.org.uk NY Horizons - leaflet
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ALCOHOL BRIEF INTERVENTION
City of York |
Out of hospital
Out of hospital care (YTHFT community contacts) – only available through an N3 connection
GP Practice OPEL Reporting System
Home from Hospital Service (NYCC only)
NHS Continuing Care
- Continuing Healthcare (CHC) information and application forms (including Fast Track assessment)
- Children and young people's continuing care national framework
- CCC generic inbox for any enquiries: hnyicb-ny.ccc-referrals@nhs.net
Suicide / Bereavement
- Referral
- Support
Voluntary Sector
Care of elderly and frailty
Frailty Referral Options
Selby Frailty Clinic (available to Selby Town PCN and Tadcaster and Rural Selby PCN practices only)
Nimbus Care Frailty Crisis Hub - A&G support
For York City residents only.
An MDT approach for patients with a diagnosis of frailty who are in or nearing a crisis situation e.g. carer strain, increased confusion, frailty syndromes etc. The team are available to help support GPs and other primary care clinicians in managing these cases.
Call 01904 928844 and ask for discussion in Frailty Hub (YICT contact number) - available Mon-Fri 8am-8pm & Sat-Sun 10am-6pm.
Urgent Community Response (UCR)
Covers all of the Vale of York area.
2 hour response to patients where it is likely that an ambulance would be called leading to an admission without a UCR assessment. UCR coordination is provided by Community Response Team who work closely with the Frailty Crisis Hub and are co-located in the same space Mon-Fri 8-4.
Important to note that GPs and primary care clinicians can refer directly for a UCR via 01904 721343 Mon-Fri 8-8.
A large proportion of cases discussed within Frailty Crisis hub A&G support line result in UCR assessments, this is at the discretion of the clinical team (GPwER in frailty and CRT clinician in the hub).
Frailty SDEC
Previously known as RAFA, this is a new unit which has recently opened on Ward 24. Open 7 days a week 8am-8pm, call 01904 725119. The patient must be discussed with the doctor/ACP working on the unit or the geriatrician on call before admission can be accepted.
The patient must have NEWS <5, be able to sit in a chair (unless normally nursed in bed), have no infective symptoms (e.g. D&V, suspected COVID etc), not be a 'barn door' admission e.g. suspected stroke, NOF # etc.
York Hospital at Home (formerly Frailty Virtual Ward)
Hospital at Home (formerly Frailty Virtual Ward) is a service for frail older people as an alternative to hospital admission with hospital-level interventions. It is led by a consultant geriatrician and the team is the same MDT structure as you would find on a traditional hospital ward. We can currently only accept patients living in the York or South Hambleton areas but expect to expand to Selby Town, Tad/Rural and Ryedale. Patients must be over 65 with CFS≥4 and can be safely managed in their own home (including care homes). Patients must be referred by a healthcare professional (they cannot self-refer).
Please ring to refer on 01904 721483 (M-F 8-4). For more information about our service contact Rachel.davison9@nhs.net
'Step Up' Beds at Fulford Nursing Home via UCP Service - 0300 330 0275
- For City of York residents
- Flowchart - only available via an N3 connection
- UCP Service Poster - only available via an N3 connection
Warm and Well
Directory of support services to support the public and professionals during winter
The below documents include a directory of support services, aimed at supporting the public and professionals during the winter months, with a specific focus on community and frailty elements:
- DoS Information for Health and Care Professionals
- DoS Information for the public
- Looking after you and your family this winter - leaflet
York and Selby Dementia Information Service
- Stroke Service - Live from 23 April 2019
Social Care Advice for over 50's
Falls Referrals
- GPs and other referrers can refer patients who have fallen or who are at risk of a fall to the Community Therapy Services for assessment and management by Physiotherapists, Occupational Therapists and assistants.
- The assessment of falls can be done through the following networks:
- Patients who have fallen and are identified by Yorkshire Ambulance Service can be referred to the Intermediate Care Team for assessment, treatment and support.
- Where needed, housebound patients who are at risk of a fall will be reviewed using a falls-assessment risk tool and referred to the appropriate service by their District Nurse via the Single Point of Access (SPA) phone 0300 330 5444.
- GPs and other referrers can refer to Community Therapy Services if they believe a patient is at risk of a fall, or if they have fallen.
- Referral Form
Please note: that only physiotherapy and occupational therapy elements related to falls will be assessed and treated by the Community Therapy Team