Hospital Based Complex Clinical Care is a specialist ward run by an older adults’ team, primarily to support older people whose care needs cannot be met in a community setting such as at home or in a care home. They specialise in managing patients living with severe frailty, those at the end of life and patients with severe chronic wounds or other high nursing needs.
When a patient is accepted, they are initially brought for an assessment period of up to 6 weeks. If at that point (or before if there is clear improvement) their condition has stabilised then we will start planning a discharge back to the community. If patients are felt to meet criteria then this will be reviewed 3 monthly. It is important that patients and their families are aware of this at the time of referral.
The focus of care in ward 1 is primarily on symptom control and as such, access to invasive therapies (such as IV antibiotics, IV fluids and investigations) and to rehabilitation services is limited. If you think that you patient would benefit from these then please consider an alternative pathway.
JH & JB 26/6/26
Who to refer:
Anyone aged 18years or over with complex needs that cannot be met in the community from East Lothian. Priority is given to those over 65yrs old or with a terminal diagnosis.
Examples of suitable patients include:
- A person nearing the end of life where it is not possible to meet their care needs at home (Note: we will explore options to increase care before approving the referral)
- High nursing needs such as complex wounds
- Complex palliative care needs e.g. rapidly escalating symptoms requiring stabilisation (please consider Hospice at Home as an alternative)
- A person with a progressive neurological condition who is no longer supportable in the community (Please highlight if this is due to behavioural disturbance)
Who not to refer:
- People under aged 18yrs
- Patients who are acutely unwell and for active management including IV antibiotics/ IV fluids/ investigations.
- People where their needs could be met with an increased package of care (Please refer to SPOA team)
- People with uncontrolled symptoms who have not yet had input from the community palliative care team (unless rapidly approaching end of life and unsupportable at home)
- People with nasogastric tubes for managing their nutrition and medication (please discuss if you feel they are still appropriate, PEG tubes are supportable).
- People without a clear plan for escalation being discussed
- People where they or their families have complex spiritual or psychological issues requiring specialist support – they will be better supported in the Hospice
- Younger patients with complex but stable conditions where admission is unlikely to make a meaningful impact on their long-term care needs
How to refer:
Prior to referral, please discuss the criteria and limitations of ward 1 with the patient and/or family.
Please review their wishes regarding resuscitation and escalation (for patients who meet the criteria for HBCCC, resuscitation or escalation are rarely appropriate)
Please give them the leaflet for ward 1: ELCH WARD 1 HBCC LEAFLET DEC 25
To refer please complete the SBAR (see links below) and email to the address at the bottom of the form.
