The One Care Home Team offers proactive support for residents in Barnet care homes through comprehensive assessments and individualised care planning, facilitated by a team of healthcare professionals, including community matrons, physiotherapists, and occupational therapists. Virtual multi-disciplinary team meetings are held twice weekly for collaborative care coordination.

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