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 from Barnet, Enfield and Haringey Mental Health Trust (BEHMHT). GPs and care homes are encouraged to join these meetings to present their case.

Eligibility Criteria

Inclusions

For OCHT community matron:

• newly admitted residents who require a holistic geriatric assessment
• existing residents who have complex care needs.

For OCHT therapy:

• recent decline/change in mobility or function where the patient is medically fit for therapy
• recent change in function where a patient requires a seating/positioning assessment and is at risk of acute deterioration
• clearly stated rehabilitation goals 
• rehab within care home to facilitate safe discharge to residents own home
• 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+.

Exclusions

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

For OCHT therapy:

• residents who have don't have any specific rehabilitation goals
• residents who need a wheelchair assessment 
• early stroke interventions (stroke within last two years) 
• home visits and equipment ordering for patients intending to leave the care home.

How to Refer

Locations

One Care Home Team