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HIV Neuro-Cognitive Impairment (HNCI) & Complex Physical Care HIV Admission

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

  • To maximise the independence of people living with complex HIV-related conditions, including neurocognitive impairment

  • To provide assessment and multidisciplinary rehabilitative care to support patients to achieve their maximum potential and regain their independence

  • To provide patients with adherence support

  • Symptom control, stabilisation and/or psychological support

  • To prevent acute hospital admission

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.

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

HIV Pathway

HIV Pathway admission criteria

  • Adults 18 years of age and above
  • The client has rehabilitation needs
  • The client is registered with a GP (Funding is through the ICB)
  • There is a move-on plan for discharge

Referrals

To discuss or make a referral, please contact our Admissions Manager by telephone at 020 7613 6347 or by email: admissions.mildmay@nhs.net

Use the referral page to download forms for:

  • HIV Medical Referral

  • HIV Nursing

  • Homeless Medical Care Pathway

  • REBUILD Pathway

  • Social Care Questions for Admission

Description of HIV Pathway

As with all our care pathways, a patient’s care needs are assessed within the first three days of admission by the medical and nursing team, and a named nurse is allocated.

 

A key worker is then appointed from the MDT. Patient care and rehabilitation are 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.

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Patients on all pathways 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.

Therapies and inputs (all care pathways)

Patient needs vary. These are some of the rehabilitation treatments, techniques, social work support and educational programmes used within the team:

  • Adherence

  • Art therapy

  • Catheter care

  • ​Chaplaincy input

  • Cognition work

  • ​Communication

  • Continence management

  • Cooking safety assessment

  • Counselling and emotional support

  • Decision making and planning

  • Diabetic management

  • Drug and Alcohol Rehabilitation and stabilisation

  • Enteral feeding

  • Finance management, applying for social support, housing and benefits

  • Health promotion

  • Healthy living/living well

  • HIV information and education

  • Increasing/maximising mobility​

  • Increasing strength and exercise tolerance

  • Life skills

  • Managing activities for daily living – washing, dressing, etc

  • Memory work

  • Nutritional awareness and support

  • Orientation

  • Pain control

  • Pet Therapy

  • Problem solving

  • Risk management

  • Self-medicating and managing medicines

  • Sexual health information and education

  • Skin care and pressure area care

  • Stoma care

  • Symptom control

  • Using resources in the community

  • Using specialist care equipment

  • Wound Care

End of Life/Palliative Care (all care pathways)

Patients requiring this pathway will always be allocated the next available bed.

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.

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

Palliative Care

Mildmay’s multidisciplinary team

  • Medical Director

  • Art Therapist

  • Chaplain and volunteer chaplains

  • Dietitian​

  • Junior Doctors

  • Liaison Psychiatrist

  • Matron

  • Nursing team of Registered General Nurses, Registered Mental Health Nurses and Healthcare Support Workers

  • Occupational Therapist

  • Physiotherapists

  • Psychologist

  • Lead Social Worker and Safeguarding Lead

  • Social Work Assistant

  • Speech and Language Therapist

  • Substance Misuse Recovery Worker

  • Therapies Assistant

  • Volunteers

Inpatient facilities

  • Twenty-eight ensuite single rooms (including two anti-ligature rooms)

  • Two wards, each with a communal lounge and kitchenetted for patient use

  • A well-equipped physical rehabilitation centre

  • Occupational therapy assessment centre

  • Specialist therapeutic equipment

  • Laundry facilities

  • Tranquil courtyard garden and conservatory

  • Digital Inclusion Room

  • Chapel

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

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