hospital at home · hospital at home in fife bed 1.1 bed 2.3 bed 4.2 a service set up as an...
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Hospital at Home
Frailty and Hospital at Home
17th March 2016
Pam Livingstone and Gwyneth Thom
National Definition of Hospital at Home December 2013
• An episode of specialist care delivered at home as an alternative to acute hospital care and where the care is overseen by a consultant/equivalent specialist. An equivalent specialist would include Associate Specialist, GP with an interest in this type of care, Consultant Nurse or AHP or Specialist Practitioner who must be case load holding practitioners.
• The locus of care is usually at home but could be in a care home if the individual is usually resident there – or is ‘stepped up’ there by the team.
• ‘Stepped up’ care in this context is when a more intensive response is required, but the individual does not require admission to hospital and could go to a temporary place of residence to get that care, for example a care home.
Community Hospital beds
Hospital at home
Day Assessment, Treatment and Rehabilitation
Intermediate Care
Referrals to Hospital at Home and Intermediate Care
Single Point Of Access in each area
Hospital at Home in Fife
Bed 1.1 Bed 2.3 Bed 4.2
A service set up as an alternative to hospital admission for frail
elderly people living at home in Fife.
OR
A service which supports patients being discharged from hospital in
a timely manner for completion of treatments and frailty pathways.
Less need for long term institutional care as result of above.
Work within Health and Social Care Partnership to facilitate above.
Where are we? There are 3 Hospital at Home teams across the
whole of Fife co-located with our Intermediate Care Services.
• Adamson Hospital, Cupar
• Whytemans Brae Kirkcaldy
• Queen Margaret Hospital Dunfermine
The H@H Team
• Consultant Geriatrician
• GP with Special Interest sessions
• Specialist Nurse Practitioners
• Community staff Nurses
• Healthcare Support Workers
• Pharmacy / AHP
• Admin support
Service Parameters
• Predominantly for elderly people > 65 years or younger people with recognised frailties
• Health needs must be able to be met safely at home
• Meet criteria for referral to H@H
Referral Guidelines
Problems Included Problems Excluded
Delirium (chest infection, UTI)
Dehydration
Reduced mobility (chest infection,
UTI or muscular)
Chronic disease exacerbations
(COPD, AF, PD, CCF)
Cellulitis / Leg ulcers
Diabetic foot infection
Falls (no #s)
Pain management
Palliative care (acute)
Stroke
Cardiac chest pain
Lower leg fracture
GI bleed / acute abdomen
Head injury (loss of
consciousness)
Need for high level care eg.
Need for MHDU care
Acute abdomen
Functional decline / unmet care
needs in community
The Virtual Ward
• Daily nurse review • Daily ‘ward’ round
– Review progress / obs – Medication review – Results reviewed – Management plan
• Comprehensive Geriatric Assessment - follow frailty pathways such as delirium, cognitive
impairment, falls
• Rapid access to: – Treatments -IV Abx / Scut fluids / IVI / O2 / nebs – Investigations -ECG / bloods / Xray / USS / CT – AHP intervention & Equipment
• providing the same level of care that would be expected in hospital for that condition
• If need hospital care they are admitted
Outcomes
• Quicker response than being admitted to hospital
– rapid medical assessment with CGA
– early Geriatrician input
• Care tailored to the individual
– maintain a patient’s independence
– continuity of care
– seamless transfer of care within ICASS
• As little disruption to normal lifestyle as possible
– Familiar environment
– Continue with usual social contacts
• Shorter length of stay
– don’t have the delays OR morbidity associated with hospital stay
• Family and carers involved all the way through
THE PATIENT EXPERIENCE
’it gave me such self confidence
and assurance when the nurses
came in to check on me. They are
a magnificent team that couldn’t
have been more helpful and
highly professional’
'thank you H@H team for all you did
for mum in her final days -you treated
her with dignity and listened to what
she wanted as if she were your own
mother. I cannot thank you enough'
