The Home Not Hospital Services

Home Not Hospital Services Falls Prevention and Home Support Referral Criteria

Age UK Harrow (formerly Age Concern Harrow) is pleased to be launching three new exciting support services to Harrow patients age 60+. These are 12 month pilot services that will be based at STARRS in Northwick Park Hospital and each has been developed thanks to the Innovation Fund to develop integrated care through innovation and joint working. Please take the time to read the outline of each of the three services. Each has a Service Description, Referral Criteria, and Referral Process.

If you have any questions about any of the services described below, please feel free to contact Chitra de Caires on 020 8861 7994 or e-mail her at: [email protected]

The ‘Home Not Hospital’ Services

Home Support Page 3 - Falls Support Page 4 - Night Care

1 Home Support

Service Description

The Home Support service will support patients age 60+ when they are discharged from hospital but need additional support for up to 6 weeks afterwards. The service seeks to ensure that patients do not have to stay in hospital any longer than necessary.

Working with the STARRS team we will assess patients who are referred to us, and if we are able to support them we will carry out a thorough assessment of their needs and draw up a timetable of support to be provided by our network of volunteers. A comprehensive list of the types of support we offer can be found in Appendix 1.

Referral Criteria

Each patient will be screened to see if they would benefit from this type of support. The following two criteria apply.

 Aged 60+  Potential delayed discharge due to lack of support listed in Appendix 1

Referral Process

We accept referrals from GPs, the discharge team and STARRS, either prior to admission or currently staying as an inpatient in hospital.

If you feel you have a patient who would benefit from this service you can contact us on: 020 8861 7994 or email Chitra de Caires on: [email protected].

2 Falls Support

Service Description

We will support the existing Falls Service at STARRS by offering non-clinical support to patients who are deemed at risk of a fall. We have a network of volunteers who are trained in Falls Prevention Therapy and can offer the following support:

 Develop an individualised support plan  Regular adapted Otago chair based exercise in their homes for up to 6 weeks  Weekly telephone call or volunteer visit to check all is well  Refer them to group exercise sessions once the 1:1 is over  Arrange handyperson visit and spot potential hazards  Replace light bulbs, replace walking aids etc  Signposting to relevant support (Home Health Clinic, alcohol support group etc)  Work with and motivate the older person to want to stay safe

Referral Criteria The following criteria apply:

 Aged 60+ and at risk of a fall and have had two falls or less.

Referral Process GP Referral You can use the updated STARRS referral form that now includes the Age UK Falls Support. For an electronic EMIS Web or Vision form please contact Jason Nash on [email protected]

Self-Referral. For patients who would like to access the service themselves they can make their initial enquiry to AGEUK HARROW on 020 8861 7980 and ask for the HNH Manager who will advise of the process. If you would like copies of the self-referral to display at your practice please contact AGEUK Harrow on 0208 8617980

3 Night Care

Service Description The night care service offers care support to patients over 65+ who are being discharged from hospital and may need immediate personal care support for overnight assistance. This service input will facilitate a maximum of one night’s support, or two nights of drop-in visits throughout the night. The focus is on supporting patients and their carers as they are discharged home from hospital. The Night drop in service is a short-term project to meet an immediate need on discharge from hospital and will complement other planned health and social care services.

Referral Process Referrals will only be accepted from the STARRS Team and Hospital Discharge teams.

Referral criteria One night care

 Patients who are 65+ who have no support at home and need support for their first night back home.  Patients are independent during the day but may have specific needs during the night.  Patients who may not need a hospital admission but need observing during the night.  Patients who live with a carer, who is also vulnerable and in receipt of or eligible for social care assessed services  Potential delayed discharge due to lack of support

Hourly drop in service

 Patients who have an identified need during the night for the short term night drop in service are entitled to 2 night’s service to assist with the transition from Hospital to home. Times will be agreed with the patient and two carers will visit the client at home.

4  Patients who have been referred for the one night care element of this project may need a drop in the following night to support the patient. No more than 1 whole night and 1 night’s drop in service can be provided to each patient. Please be aware that this service cannot be substituted for a night care package.

Patients cannot self-refer. Referrals can only be made by the STARRS team and the discharge team who will be responsible for the care assessment and home risk assessment. The assessments must be completed before the referral for night care provision. If the patient needs additional care support a care package must be in place before Home Not Hospital Project Manager will accept the referral.

Appendix 1 (Not applicable for night support) Home Support Service What we CAN do What we CANNOT do  Liaise with family or professionals to ensure that  Provide personal care/housework there is enough food and drink available and that your  Go into a home unless someone is home is warm once you are home present  Ensure you are able to prepare light snacks/drinks  We are unable to help with eating and  Food and drink prompts drinking  Prompt you to take your medication  Administer your medication  Arrange for the collection/ delivery of prescriptions by liaising with your GP or pharmacist  Alleviate social isolation by matching you with a  Shop on your behalf, but can refer you to short-term visitor/signposting you to local groups a shopping service  Build confidence to ensure that you feel safe making local journeys by foot/public transport  Maintain your independence by supporting you to access social activities during the day  Signpost you to other services  Help you with administrative tasks such as sorting out  Handle your money and write cheques or your post with you pay bills for you  Do your banking  Provide a falls support exercise programmes to help  Respond to emergencies improve/maintain your mobility and decrease the chance of falls and readmissions to hospital