The aim is to ensure that the patient has what they need once discharged and to let other services know that the patient has had a hospital admission.
Typical actions that come from the huddle are:
- for the At Home First Co-ordinator (AHFc) to complete the 5’qs/5 m’s identification of need assessment
- the AHFc will complete a follow up call
- the Pharmacy Technician to complete the 5 q’s or follow up call – these are mostly patients with polypharmacy, complex medications, issues that are known around medications and changes to medication
- task to other teams such as Parkinson’s, Heart Failure, Respiratory, Falls Team, Palliative Team, Diabetes Team, Community Matrons– to let them know of the patient’s discharge
- to ensure that if District Nurse (DN) input is required that the referral has been received
- Luton Intermediate Care service provide information on patients that require a more urgent screening
Using the Population Health Risk Tool (winner of the Health Service Journal Patient Safety Award) we identify patients who:
- are 65 years old and older
- have not had face to face contact with Cambridgeshire Community Services NHS Trust (CCS) staff for a year
- not housebound
- not in a care home
All patients contacted are sent the At Home First Introduction letter and leaflet. The letter has further information on the back to advise patients what to do when they feel unwell, when to call 111 and when to call 999.
The At Home First Co-ordinator (AHFc) will arrange and facilitate these meetings that take place virtually over Teams using iPad’s put into the care homes by CCS.
The At Home First Team facilitates and coordinates the GP Practice multidisciplinary teams (MDTs) that take place in Luton. This is a forum to get professionals together to discuss the more complex patients and decide on any actions that may be needed.The MDT Meetings are virtual via teams and consist of GP’s, practice staff, AHFc, community matron and sometimes other teams such as falls, diabetes and respiratory. Other professionals are invited as required.
