Information
The aim of the Hospital at Home (H@H) service is to deliver specialist coordinated, comprehensive assessment for older adults as an alternative to hospital admission. The team will take referrals from Flow centre – GPs/ANPs within General Practice, Scottish Ambulance Service, Lothian Unscheduled Care Service – and is intended for patients who would ordinarily be admitted to hospital at the point of crisis. The team will support early discharge facilitation for appropriate patients through referrals from medical and senior nursing staff, at front door services in acute hospital.
Service Provision
- H@H aim to undertake an Assessment Visit within 4 hours of referral for GP referrals and within 24 hours for facilitated discharges. For complex and high acuity we aim to assess within one hour.
- Initial assessment will be by Nurse Practitioner or Advanced Nurse Practitioner/Doctor if complex concerns or NEWS at time of referral of 4 or above.
- All patients will be seen by a Doctor within 96 hours or less if acute concerns highlighted from initial assessment.
- Immediate assessment including history taking, examination, cognitive assessment and functional assessment (using standardised assessment tools (NEWS, MMSE, GCS as appropriate, etc.).
- Bedside tests. Lying and standing BP, Blood Glucose Levels, Temp, BP, Pulse, Saturations, ISTAT blood tests.
- Routine Investigations (routine bloods and ECG as standard).
- Full access to diagnostics support, as would be the case with inpatient services however access to radiology, endoscopy, colonoscopy etc. will be as determined necessary by senior medical review.
- Access to diagnostic results as clinically necessary.
- Full use of TRAK functionality to record all activity and use of hospital electronic patient management systems for ordering investigations.
- Provision of treatment dependent on condition; IV therapies (H@H utilise antimicrobial management developed by H@H teams and microbiology). IV/SC fluids, nebulised solutions. This list is not exhaustive. Blood transfusions can be arranged via Liberton Day Hospital.
- Review and rationalisation of medications.
- A twice daily ward ‘huddle’ and safety brief.
- A twice weekly ‘virtual ward round’ and review of cases with goal setting.
- Maintenance of a clinical record on TRAK.
- Future care planning with patients and relatives where appropriate.
- Managed at home with care equipment.
- Maintenance of an information pack accessible by the patient. This will be subjective to change as we aim to go paperlite.
- Discharge planning and discharge communication to General Practice in line with standard Hospital Procedures and use of SMR01 Hospital Discharge letters.
- Communication with General Practitioners, District Nurses, Community Psychiatric Nurses, Pharmacists, Consultants in Psychiatry of Old Age, Out of Hours etc. as necessary.
Prior to referral, agreement and consent must be obtained from the patient/carer/and or relative. The patient and their family will have an understanding of the “Hospital at Home” concept and an acceptance of the philosophy of care at home as an alternative to admission.
Who to refer:
Regardless of source of referral, patients will need to fulfil basic criteria as follows:
- Midlothian resident (some patients e.g. in Penicuik GP practices are resident in the Borders and would be excluded).
- Must have an acute problem that would otherwise require admission to / ongoing stay in hospital.
- Frail Patients over 65 years old – Those younger than this may be discussed on a case by case basis.
Referrals out with the criteria will be reviewed by the H@H consultant for suitability for the H@H service.
Patients may be:
- At home
- At home, currently receiving input from other services e.g. Rapid Response Team
- In a care home facility
- In the Intermediate Care Bed Unit at Highbank
In assessment areas of the acute hospitals – Emergency Department , Acute medical units:
- In these cases, the referral can be made by the relevant senior clinicians and ANPs within these departments/units
Who not to refer:
Currently, H@H does not routinely see the following groups:
- Younger (<65) acutely ill patients
- Older patients after a prolonged hospital admission
- Patients who are dying
- Patients who are not acutely ill but need a second opinion
Hospital at Home Exclusion criteria
- Possibility of acute coronary syndrome
- Any acute orthopaedic issue
- Acute stroke
- Acute abdomen
- Head injury
- Patients who have these issues may be referred AFTER being seen in the appropriate acute setting and any relevant treatment started
How to refer:
GP, SAS, LUCS, ANP (within GP practice) referrals through Flow Centre on:
03000 134 000 24 hours/7 days per week (this is subject to change dependant on Service requirements and referral criteria).
For referrers in daytime GP practices, after the referral has been accepted then please send a SCI Gateway Referral:
Midlothian Community Hospital >> Medicine of the Elderly >> Basic Sign Referral
Please do not send a SCI Gateway referral unless the referral has already been accepted by Flow Centre as the team may not see it and the referral will not be acted on.
H@H will also consider referrals from established community services such as Community Respiratory Team (CRT), District Nursing Service after discussion with GP, Heart Failure Nurse Service and Learning Difficulties via GP.
H@H are happy to discuss referrals directly if any concerns.
Hospital discharge via direct contact with H@H Team on 07773193921.
