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Hospital at Home

Hospital at Home 


What is Hospital at Home?

Hospital at Home is a multidisciplinary acute care team, made up of NHS Lanarkshire consultants, advanced assessment nurses, allied health professionals and community psychiatric nurses.

As an alternative to hospital, the team will deliver specialist, coordinated and comprehensive assessment and care to frailer older adults in their own homes.

The team will link in with South Lanarkshire Council Social Work Resources and the Integrated Community Support Team who will provide additional community support to patients when required.

The team will launch in the Hairmyres Hospital catchment area on April 20, 2015.

It will initially be offered to patients in East Kilbride and Strathaven and will incrementally roll out to cover the full hospital catchment area which also includes Hamilton, Uddingston, Larkhall, Blantyre and Bothwell in the following months.

Why now?

We know research shows that most older people would prefer to remain in their own homes, with support if they are unable to look after themselves. At the same time, as people live longer, older people are presenting to hospital in increasing numbers year-on-year.

Early evidence shows that Hospital at Home will provide safe, effective person-centred care, equivalent to the acute hospital, in the patient’s own home.

The key aim is to improve patient experience and outcomes. Accordingly, to reduce admissions in a safe and effective way, imminent roll-out of the Hospital at Home model has been agreed for the Hairmyres Hospital catchment.

Has this type of service been tried before?

Yes. The Hospital at Home project will be based on the same model as the Age Specialist Service Emergency Team (ASSET), which has been piloted in some areas of North Lanarkshire.
The team, who originally formed under the national Reshaping Care for Older People programme, is currently operational in Airdrie, Coatbridge and Cumbernauld/Kilsyth, which is in the catchment area of Monklands Hospital.

The team was created in 2011 and serves a population of around 160,000 people. ASSET has supported approximately 8 out of 10 people referred to remain at home rather than being taken to hospital. The team treat a range of complaints and conditions.

What have been the main benefits where ASSET has been operational?

There have been several marked benefits including:

  • ASSET has been referred 2864 patients in 29 months of operation (over five patients per day, on average)
  • 76% of these patients were managed at home
  • The rise of over 75 hospital admissions in the area served by ASSET has been less than the rest of Lanarkshire
  • Evaluation by the University of the West of Scotland demonstrated high levels of satisfaction with the service among patients and carers.

What patients are eligible for the Hospital at Home service?

The team will treat a range of complaints and conditions including infections, pneumonia, heart failure, COPD (chronic obstructive pulmonary disease), delirium or falls.

Predominately the service is for people over 75 but Hospital at Home can review patients under 75 if frail.

What conditions does the team not treat?

There are several conditions the Hospital at Home team doesn’t treat including chest pain, stroke, DVT, acute surgical or orthopaedic crisis. These will be treated in hospital.

How are referrals made?

Patients will be referred to the service through the Emergency Response Centre (ERC) when GPs refer for hospital admission.

Where appropriate, the Hospital at Home team will be offered to provide hospital level care in the person’s own home.

The Hospital at Home team will also work closely with the Scottish Ambulance Service to avoid hospital admissions.

(The ERC is a single point of access for GP’s arranging emergency admission, and is a joint project with the Scottish Ambulance Service. This ensures patients are directed to the most appropriate place, and are seen by the most appropriate person.) 

How will the team work in practice?

When a patient is referred to Hospital at Home, the team aim to visit within one hour to assess if treatment at home is feasible. 

A nurse will examine the patient as well as carrying out tests such as a cardiograph and blood tests so, when the consultant arrives, they can study the test results and further examine the patient.

The team will then develop and deliver a treatment/ management plan for that patient working with other services as required.

A daily virtual ward round, undertaken in Hairmyres Hospital, will be carried out to review and update these plans. Average length of stay with the team is 4-5 days.

Some key capabilities of the team will also include:

  • Immediate, specialist and comprehensive patient assessment
  • Just like inpatient services, the Hospital at Home team will have full access to procedures and equipment to establish a diagnosis. This includes, where appropriate, radiology, endoscopy and colonoscopy.
  • Direct links to hospital laboratories and X-ray facilities to reach diagnosis
  • Anticipatory Care Planning (ACP) with patients and relatives where appropriate. (The ACP is a record of the preferred actions, interventions and responses that care providers should make following a clinical deterioration or a crisis in the person’s care or support.)
  • Full use of hospital records.

Hours of Operation

The team will operate from 8am to 6:30pm, seven days per week.

New patients will be accepted from 8am to 4pm Monday – Friday from the ERC.

Referrals will be taken from care homes from 8am-5pm, seven days a week.

Is the Hospital at Home Service different from existing services like the Integrated Community Support Team (ICST)?

Yes. The ICST has brought together nurses, physiotherapists and hospital discharge rehabilitation staff from NHS Lanarkshire with social workers, home care workers and occupational therapists from South Lanarkshire Council. The focus has been on supporting discharge from hospital and prevention of admission.

Members of the ICST work together to devise and implement the best possible course of support for the person and their carer. As well as palliative care, the ICST also offer round-the-clock support to people who have just been discharged from hospital, helping them regain independence to prevent unnecessary readmission to hospital.

The Hospital at Home team differs as it offers immediate care to cases that have acute medical issues and would otherwise need hospital admission. However, it’s important to stress these services will be provided together and in partnership.

So, will all the community teams work together?

Absolutely. All care will be delivered in partnership and Hospital at Home will become an integral part of services available to people in the community.

Joined up working will be a key feature between the teams and other services/partners.

For example, a patient who’s been referred to the Hospital at Home team may well receive ongoing care and support from the ICST. Similarly, an ICST patient whose health and care needs are nearing the point of hospital admission may be referred from the ICST to Hospital at Home.

The key aim is to have the right care in the right place at the right time.

Are unpaid carers' needs taken into account by Hospital at Home?

Yes. Part of the nature of the Hospital at Home service means that we spend a significant amount of time in direct communication with the carer of the person who is receiving treatment.  Carers and their concerns are fundamental to patient welfare as well as hugely important in their own right, many carers being frail themselves. Accordingly, carer welfare is part of our routine assessment.  We work closely with - and can refer to - organisations like the Lanarkshire Carers Centre and South Lanarkshire Carers Network, who provide a breadth of advice and expert support to carers. We signpost to North Lanarkshire Carers Together in carer information packs we distribute.  We can also refer people for a carer’s assessment, which is a discussion between the carer and a trained person from the local authority. The assessment will identify support needs and how these could be met. 

Are existing supports for carers being used by Hospital at Home?

Yes. There are two Co-ordinator for Carers based within North Lanarkshire Carers Together and two Carer Development Officers employed full time by South Lanarkshire Carers Network. Along with the Co-ordinator for Carers in each acute hospital and the Co-ordinator for Carers (Mental Health), they form the Carer Support Team and work throughout the catchment areas covered by the Hospital at Home. Much of their work in the community focuses on working with GPs to raise awareness of carers’ issues and to ensure carers are identified and given the information and, where appropriate, the support they need to continue to care. Hospital at Home will continue to work closely with these vital and well-established networks to ensure the needs of carers are treated as a priority.

Additionally, the Hospital at Home team also work closely with the Integrated Community Support Team. A procedure is in place ensuring that when the Hospital at Home team receive a patient referral they make contact with ICST to find out if the patient is already known to the team or District Nurses. As a matter of course ICST also inform carers about carer support organisations, like South Lanarkshire Carers Network and, where required, make contact with these organisations to arrange support, advice and help.
For more information on carer supports visit:
South Lanarkshire Carers Network
http://www.slcn.co.uk/ or
Princess Royal Trust for Carers Lanarkshire Carers Centre
North Lanarkshire Carers Together

Who do I contact for more information for Hosptial at Home?

For more information please email:
g.ellis@nhs.net or Trudi.Marshall@lanarkshire.scot.nhs.uk

For media queries contact euan.duguid@lanarkshire.scot.nhs.uk or call 07917041853

The Hospital at Home is a strand of the integration of health and social care.
For more information on integration visit: http://www.nhslanarkshire.org.uk/About/HSCP/Pages/FAQs.aspx