The One Care Home Team (OCHT) is led by a clinical lead nurse and is composed of the following healthcare professionals:

• community matrons
• physiotherapists
• occupational therapist
• technical instructor
• rehab support worker
• trusted assessors.

The team aims to provide proactive support to residents living in Barnet care homes through comprehensive assessments and individualised care planning.

Virtual multi-disciplinary team (MDT) meetings are held twice a week on Tuesdays and Thursdays, with alternating geriatricians from Barnet General Hospital and an old age psychiatrist. GPs and care homes are encouraged to join these meetings to present their case.

Eligibility Criteria

Inclusions

For OCHT community matron:

• residential or nursing care home resident in Barnet 
• newly admitted residents in Barnet Care homes 
• care home residents in need of Geriatrician and Old Age Psychiatrist (OAP) input.

For OCHT therapy:

• a recent decline/change in mobility or function 
• seating/positioning assessment required due to recent deterioration 
• clearly stated rehabilitation goals 
• patient has new or recurrent falls.

For OCHT MDT meeting:

• advice and support required for complex residents living in Barnet care homes.

For OCHT MDT old age psychiatry:

• aged 65+.

For OCHT trusted assessor:

• existing care home residents medically fit for discharge who require a comprehensive need assessment 
• new medically fit patients in hospital who are referred from Brokerage Team and Social Services for a placement in a Barnet Care Home. 
• care home postcode within Barnet Borough 
• care Home residents who are admitted in Barnet General and Royal Free Hampstead hospitals only.

Exclusions

• acutely unwell, requires rapid response or urgent care in the community.

For OCHT community matron:

• sheltered accommodation and extra care living 
• residents in care homes outside of Barnet  
• non care home residents  
• residents of homes without geriatric specialism / population 
• residents needing to be seen by a clinician in emergency cases/ with rapid response element. 
• residents requiring TVN specialty (regular dressing/wound care) 
• referrals for regular insulin administration for care home residents  

For OCHT therapy:

• patient has no rehabilitation potential or unrealistic goals 
• patients who are not medically well 
• referrals for equipment only 
• referrals to provide wheelchair assessment 
• early stroke interventions 
• behavioural or mental health support/intervention 

For OCHT trusted assessor:

• home care, sheltered or assisted living 
• care home outside of Barnet Borough 
• patients admitted in hospitals that are not Barnet General Hospital or Royal Free Hampstead.

How to Refer

Locations

One Care Home Team