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NHS@home

Checked: 23-11-2023 by Vicky Ryan Next Review: 23-11-2024

Overview

The NHS@Home team provides clinical care for people who are acutely unwell, in their own homes across BNSSG. The service provides an alternative to an acute hospital admission and supports earlier discharge from hospital.

The service is run in partnership between Sirona, UHBW, NBT and Severnside Integrated Urgent Care Service (BrisDoc), with input from the GP Collaborative Board. Watch this video to find out more about how the service works. There is also a GP webinar which explains the service and how primary care can refer into it in detail - https://www.youtube.com/watch?v=0pu3s51n6vY

Who are we? Multidisciplinary healthcare professionals including Advanced Clinical Practitioners (specialists in Frailty, Respiratory and Heart Failure) from the collaborative BNSSG NHS@Home team, working with Specialist Consultants from NBT and UHBW.

The service uses a mixture of digital remote monitoring (NEWS2 and bespoke questionnaires) visible on a virtual ward dashboard, telephone and video support, and face to face visits from specialist teams.

Who is this for? Adults presenting with an acute illness including exacerbations/decompensations and frailty syndrome where clinical care can be safely managed in their preferred place of care, as an alternative to admission or to support early discharge.

Who is unsuitable? Major trauma, new-onset chest pain, complex symptomatology, suspected stroke, presentation of acute mental health crisis with risk to self or where multi-disciplinary intervention is required through another pre-existing service, for example UCR.

Referring clinicians will be asked for a working diagnosis in order to plan ongoing care needs, including frequency or vital signs monitoring, diagnostics, home visits and interventions.

Who is responsible? Once a patient has been accepted by NHS@Home, the relevant healthcare professionals within the NHS@Home specialty team become responsible for plans and decisions made in relation to the acute episode of care.

Please note, however, the patient’s GP remains responsible for any long-term medical needs, for example, repeat medications for long term conditions.

The following NHS@Home pathways now provide alternatives to admissions.

NHS@home - Respiratory pathway

NHS@Home - IV antimicrobials (OPAT)

NHS@Home - Frailty pathway

A number of other pathways exist to support earlier discharges from hospital. These can be identified via this infographic.

Inclusion / exclusion criteria

Who is suitable for an NHS@Home pathway of care?

The service is suitable for adults who:

This service is not suitable for adults who:

Are presenting with an acute illness including:

exacerbations/decompensations of respiratory conditions and frailty syndrome.

Have been seen face to face by an HCP on the day of the referral to NHS@Home.
Do not require vital signs monitoring on the same day as referral, or overnight.
Have baseline observations NEWS2 <=5 (clinical discretion allowed).
Fit pathway specific criteria – see respiratory, frailty and OPAT pages for more information.
Are well enough to have the next face-to-face review with NHS@home the following day. (NHS@Home team will contact patient/carer by telephone on day of acceptance onto a pathway. If another visit is required same day this will depend on capacity).
Are willing to consider acute care at home as an alternative to hospital, and any carers present also agree to this.
Are able to monitor worsening symptoms and call 111/999 if required, with support from their carer if they have one, or independently if not.

Are not able to call for help if health is deteriorating, e.g, acute cognitive decline and/or lives alone with no family carer/friend to support.
Require interventions outside scope of NHS@Home
Have major trauma.
Have new-onset chest pain.
Have complex symptomatology.
Have a suspected stroke.
Require Intravenous fluids.
Are presenting with an acute mental health crisis with risk to self or others.
Require multi-disciplinary intervention through another pre-existing service, for example UCR.

If you are considering medical admission, please explain to the patient and their carer that there may be an opportunity to treat their condition at home rather than being admitted to a hospital bed. Please confirm with the patient and carer that this is something they would be willing to consider before contacting the WDPL.

Referral

If a patient has not been seen face to face: call SPA for Urgent Community Response on 0300 125 6789. UCR will refer on to NHS@Home if appropriate.
If a patient has been seen face to face and you are considering admission to hospital: call the Week Day Professional Line on 0117 2449283. A WDPL clinician may suggest NHS@Home as an alternative to hospital admission, based on the criteria above.
If a patient has been seen face-to-face, they meet the NHS@Home criteria and you believe they could benefit from an NHS@Home pathway of care: please call the NHS@Home Community Hub directly on 0300 125 5001 (7 days a week, 8am - 8pm).

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.