Referrals

Our data show that the majority of patients return to some form of independent living within the community on discharge from Mildmay

Inpatient Unit

Mildmay Hospital utilises a large multi-disciplinary team (MDT) to provide structured pathways of rehabilitation and care for patients with complex HIV and HAND (HIV-related neurological disorders).

Our patient-centred approach encourages patients to be active in their treatment decisions and care plan. Goal-orientated care plans work to maximise independence, and improve physical, psychological, cognitive and emotional well-being. This can lead to a reduction in incidences of readmission to hospital.

Mildmay works in partnership with the patients’ Acute Centres, Community Specialists and family and friends to facilitate the best possible outcomes for patients.

Mildmay offers three Inpatient pathways:

Pathway One: referral for both HAND and Complex Rehabilitation

Pathway two: minor Rehabilitation/Respite

Pathway three: End of Life/Palliative Care

Pathway one: referral for both HAND and Complex Rehabilitation

The average length of stay for patients admitted for HAND is 12 weeks. The minimum length of admission is four weeks

Patients requiring admission for Complex Rehabilitation are also admitted for a minimum of four weeks but this is dependent on need and treatment.

All patients accessing Pathway One will receive input from all members of our MDT as required.

A patient’s care needs are assessed within the first three days of admission by the relevant disciplines. A key-worker is then appointed from the MDT. Patient care and rehabilitation is planned and implemented with the involvement of the patient and with liaison with the referrer. Continuous assessment and evaluation of the patient’s short and long term goals is made and includes weekly MDT meetings led by our specialist HIV consultant.

All patients in this pathway have three or four weekly Discharge Planning Meetings (DPMs) to discuss the patient’s needs, progress, future needs and discharge options. DPMs involve the relevant internal and external staff and carers.

Pathway two: minor Rehabilitation/Respite

Patients requiring Minor Rehabilitation/Respite are usually admitted for two weeks but can be admitted for a minimum of one week. Extensions can be granted for longer admission time if there is an identified need.

Patients in this pathway are usually admitted for psychological support, adherence support, rest and recuperation, symptom control and pain and medicine management.

On admission patients are assessed by the medical and nursing team and a named nurse is allocated. If need is identified some patients will be referred on to our MDT, however, the length of admission for this pathway means that most of the specialist care will be administered by the medical and nursing teams with support from our MDT.

Patients needs and goals are discussed at the weekly ward rounds in liaison with the referrer.

Pathway three: End of Life/Palliative Care

Patients requiring this pathway will always be allocated the next available bed. This is the only pathway with no fixed time length.

Patients are assessed by the medical and nursing teams and are allocated a named nurse. Referrals for specialist input by our MDT will come from the nursing and medical assessments to ensure that there is excellent pain and symptom control and treatment.

Care needs and input are discussed weekly in the ward rounds.

Therapies and inputs

Due to the complex nature of HIV, patient needs vary. These are some of the rehabilitation treatments, techniques, social work support and educational programmes used within the team: