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Hundreds of patients avoid hospital stays, thanks to @Home Service

Hundreds of vulnerable patients, who might otherwise have to be admitted to hospital, are now being treated while at home, thanks to an innovative service based in Pontypridd.

The @Home Service, established by Cwm Taf University Health Board at the Dewi Sant Health Park, moves care out of the hospital and into the local community.

A ‘one stop shop’ approach brings the expertise of specialist nurses, physiotherapists, occupational, speech and language therapists, dieticians and doctors together to put together a care package.

The service has dealt with more than 1,200 cases in a year, some 60-70% of which would otherwise have had to be admitted to hospital.

Those who do go into hospital can also be allowed home earlier because of the services provided in the community.

Patients, who are often elderly with complex needs, are able to maintain their independence and improve their health while staying at home.

Lead clinician Raja Biswas said that the @Home Service represented the future of the NHS, moving care from the hospital setting into the community and bringing once fragmented services together.

“The idea is that most patients or elderly people don’t want to come into hospital. They want to be treated at home,” he said. “The @Home project offers that. The hospital goes to the person’s home and tries to keep them at home.”

Many have had frequent falls or are at risk of falls, deteriorating mobility, or are frail elderly and at risk of an approaching crisis; or patients with medical problems who may not need 24 hour in-patient care.

“A lot of the time there are family members who are worried about how a relative is managing and this serves to give reassurance that they are being looked after and cared for in the best possible environment which is their home.

Offering best possible care

“The purpose of the project isn’t to reduce the hospital admissions, it is to offer the best possible care,” he said. “The feedback we have had so far from all the patients and families who have used the service has been very good.

“They have said they have been well looked after and they have got exactly what they wanted. They would recommend us to another person which is the best possible compliment we can have.”

Senior nurse Ceri Wilson said: “We aim to provide an enhanced service to people, often have complex needs, in the community, to avoid unnecessary admissions to hospital. In recent months three teams have co-located together at the Dewi Sant Health Park aiming for a more integrated way to work.”

Meanwhile, the Stay Well at Home team of social workers, occupational therapists, physiotherapists and therapy technicians undertake assessments at the Prince Charles and Royal Glamorgan hospital sites.

The @Home service operates a Monday to Friday service while its nursing team support SW@H with a four hours nursing response seven days a week.

Team leader Samantha Sullivan said the service aimed to give advice and recommendations quickly to the referring clinician and worked in partnership with primary care services.

“We feel that the service is a piece of the puzzle that was missing. We can attend to all the issues in one sitting keeping the patient at the centre of it, not only looking at the medical side of things but also what are the crucial aspects of care that are required to keep the person at home. Every staff member believes in this service and knows it makes a difference.”

Pictured: Some of the @Home team members (left to right) Sharon Jones, Registered Nurse; Dr Kourosh Sahebi; Samantha Sullivan, Team Leader; Ceri Wilson, Senior Nurse; and Dr Maltie Badri Maharaj.

Case studies:

Patient Story – Mr X

Mr X, a 68 year old retired electrician, was referred by his GP after suffering frequent falls.

During Mr Xs assessment he described a slow and progressive decline in his mobility over the last few years.

Mr X was experiencing worsening symptoms of Parkinsons, his quality of life was starting to decline and he feared for his safety while at home.

Occupational Therapy followed up Mr X as a home visit and a number of problems were identified, for example poor positioning while sitting to stand, rugs and mats in various rooms, and no supported seating.

The Local Authority arranged a daily care package along with meals on wheels while the Occupational Therapist met with authority staff to enable the necessary equipment to be commissioned. Mr X was able to continue living at home with reduced risk.

Patient Story – Mr Y

Retired health worker Mr Y was treated in hospital for an infected knee joint and needed antibiotic treatment via an intra venous line.

When he was fit to return home after three weeks, Mr Y still needed the antibiotics treatment for another four weeks to prevent a further infection.

The @Home team met him the day after his discharge from hospital and were able to transfer that care to his own home.

Mr Y said that being home helped with his recovery. His days in hospital were long with not much to do and he recalled nights where he couldn’t sleep due to the night time activity around him.

An acute hospital bed was freed up and having his treatments at home helped with Mr Y’s physical recovery and emotional well being. He went on to enjoy a planned family holiday and continues to live an independent life.