Discharge to Assess
The HomeFirst team supports people to leave hospital, when safe and appropriate to do so, and continue their care and assessment out of hospital. Initial assessments and discharge plans which take place in hospital, are supported with care, support and further assessment in the community.
The Home First team co-ordinates hospital discharges (via the Transfer of Care hub), when further care is required, to home-based care, community hospital, interim bedded care, or long-term placement. Referrals are also made to the Community Therapy teams.
The Home First team works with Social Care, Continuing Health Care and hospital wards to plan and co-ordinate support required following discharge from hospital. Patients can be referred, when medically fit for discharge, when health and social care needs are required. This may also include community hospital placement from the Emergency Department.
In addition, Home First coordinates pathways to provide care for patients who are either Non-Weight Bearing or have diagnosed Acute Delirium. Clinical triage and assessment are made regarding Acute Delirium or Non-Weight Bearing needs, to ensure each patient meets the criteria on which funding can be approved. When accepted to either pathway, clinical review and assessment of further needs will be undertaken.
Accessing the service
Referrals can be made through HomeFirst. The Single Point of Access team will forward any query to this team.