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HIV Pathway

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-associated 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.

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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 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

Inpatient facilities

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

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

  • A well-equipped physical rehabilitation centre

  • Occupational therapy assessment centre

  • Specialist therapeutic equipment

  • Laundry facilities

  • Tranquil courtyard garden

  • Digital Inclusion Room

  • Chapel

Mildmay’s multidisciplinary team

  • Medical Director

  • Art Therapist

  • Chaplain

  • Clinical Lead Nurse and a nursing team of Registered General Nurses and Healthcare Support Workers

  • Dietitian​

  • Housing Officer

  • Junior Doctors

  • Liaison Psychiatrist

  • Occupational Therapist

  • Physiotherapists

  • Psychologist

  • Social Worker and Counsellor

  • Speech and Language Therapist

  • Substance Misuse Recovery Worker

  • Volunteers

1. 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.

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

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

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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 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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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.

We also accept referrals for

2. 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.

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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 the need is identified, some patients will be referred 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.

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

3. 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.

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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:

  • Self-medicating and managing medicines

  • Pain control

  • Adherence

  • Increasing strength and exercise tolerance

  • Memory work

  • Increasing/maximising mobility

  • Decision making and planning

  • Cognition work

  • Problem solving

  • Orientation

  • Managing activities for daily living – washing, dressing etc

  • Healthy living/living Well

  • HIV information and education

  • Nutritional awareness and support

  • Sexual health information and education

  • Using specialist care equipment

  • Cooking safety assessment

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

  • Art therapy

  • Using resources in the community

  • Counselling and emotional support

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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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