New Hospital at Home Service

Queen Elizabeth Hospital is working with a hospital and community based company, “Healthcare at Home”, to bridge the gap between hospital and home care by providing a service called “Hospital at Home.”

This will provide hospital standard nursing and rehabilitation care for patients in their own homes.  This service will be launched on 11^th February 2015 for medical patients with plans to extend this to other specialties over the following months.

Once your patient has been assessed as suitable for this treatment by the hospital consultant and Healthcare at Home Team, and a plan of care agreed, they will be transferred to their own home from Queen Elizabeth Hospital with a clear treatment plan.

The patient will remain under care of the Queen Elizabeth Hospital consultant but will receive care and treatment from the Hospital at Home team of specially trained nurses, physiotherapists, occupational therapists, therapy assistants and healthcare assistants in the comfort of their own home.  The patient will be kept on a virtual ward list at Queen Elizabeth Hospital until their treatment has finished, at which point they will be discharged from that list.  Any concerns or questions about the patient’s care will be directed to the responsible hospital consultant until discharge from the hospital list.  There will be robust governance arrangements during this period regarding advice and readmission - should that become necessary - and the provision or changing of supplied medication.

How will we communicate with patients’ GPs?

Once a decision to transfer a patient from the Queen Elizabeth Hospital site has been made, a discharge summary will be e-mailed to the GP practice on the same day, advising that the patient is being cared for in the community under the Hospital at Home team, but remains under the care of the hospital consultant. Once the episode is complete and the Queen Elizabeth consultant agrees the patient can be discharged, a final discharge summary will be sent in the usual way upon discharge from hospital.

The Hospital at Home staff can only treat your patient for the conditions detailed in the care plan.   If they have any other medical problems, they will continue to be treated by their GP, district nurse or other hospital department as appropriate.

GPs will be asked to provide FP10 prescriptions for patients that are on a regular monitored dosage system (commonly referred to as a dosette or blister pack) and all routine medicines not being administered by the Hospital at Home team.

What if a patient’s condition does not get better?

The team will be in daily contact with the hospital clinicians.  If patients, carers or relatives are concerned about any symptoms, they can contact Healthcare at Home’s ‘Care Bureau.’  The Care Bureau is staffed by nurses 24 hours a day.

If a patient’s condition deteriorates, they may need to be transferred back to hospital for further treatment.  The responsible hospital consultant will be contacted for advice during the hours of 0900-1700 and, out of hours, the medical SpR will be contacted via switchboard. The outcome may be that the medication at home may need to be altered, the patient may need to be seen in the ambulatory care unit or in the GP triage area and may need to be readmitted if clinically appropriate. There are carefully considered internal readmission pathways to maintain communication, safety and continuity of care.  Patients are advised to call 999 in a medical emergency. 

Should you have any queries or comments about this service, please do not hesitate to David Sulch, Divisional Director for Acute and Emergency Medicine at email david.sulch@nhs.net.