The service aims to prevent avoidable admissions and avoid readmissions by providing support in the community via the Barnet urgent community response and virtual ward (step-up) access.

The care process is as follows:

• contact will be made with the patient or their representative by phone, and arrangements made to visit within two hours
• initial assessment will be carried out by a qualified nurse
• patients will receive at least one visit per day
• patients will be supported within the team for up to 72 hours (on occasion, 120 hours if required)
• patients accepted on to the service will be monitored for 30 days, with this including a mixture of face-to-face visits, telephone contact, and a contact number left with the patient for them to use should they feel unwell during the 30-day period (this will be assessed at the end of the formal support).

The rapid care and response teams manage a range of conditions, including acute exacerbations and acute complications of long-term conditions, in the community. They also support frail and elderly people who have experienced a fall but do not require hospital care, and those with pneumonia or a urinary tract infection.

The service is available at short notice, into the evenings and at weekends, and it also supports rapid transfer home from urgent care centres/A&E in order to avoid hospital admission. Care is handed over to mainstream services within a few days (typically on day three, maximum day five).

The rapid response team provides patients with urgent community health care within two hours to avoid a health crisis and possible hospital admission.

Hospital@Home (Virtual Ward step-up)

The service enables patients to remain at home for up to 14 days while receiving nursing/ therapy/ pharmacy/ medical support so avoiding a hospital stay.

It is for patients with a higher acuity level than those supported by Rapid Response.

Eligibility Criteria

Inclusions

• residents of Barnet aged 18+ who are experiencing a new onset/ deterioration in a person's health that requires treatment within 2 hours.
• frail patients or have a CMC flag.
• assessed as safe to be at home with this service by a GP.
• Conditions managed include, bowel management, catheters (blocked), cellulitis, chest infection, dehydration and diarrhoea, equipment provision, falls, frailty & associated conditions, UTI/ confusion and wounds (simple)

Hospital@Home (Virtual Ward step-up)

• residents of Barnet aged 18+
• home-based care is safe and appropriate based on clinical assessment
• Conditions managed include, acute kidney injury, atrial Fibrillation (unless patient on AF Virtual Ward pathway, delirium, dementia (suspected or known where risk is deemed manageable in the community), COPD (requiring oral or once daily IM/ IV Abx and daily monitoring), falls, pneumonia, trial without catheter, UTI or Pyelonephritis, other conditions by discussion

Exclusions

• homeless patients.

How to Refer