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At Home First, Luton

What we do

Every week day we run a mede-analytics report that shows patient’s who have been discharged from the Luton and Dunstable Hospital that are 65 and over, moderately or severely frail, that have had two or more hospital attendances/admissions.

The report d shared with professionals from: Virgin Care Intermediate Care Rehabilitation Service, Pharmacy Technician, At Home First, Adult Social Care and CCS nursing services.

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

  • For the AHFc to completea follow up call

  • For 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 DN input is required that the referral has been received.

  • Luton Intermediate Care service provide information on patients that require a more urgent screening.

How to contact our service

Whether you’re an existing patient (or carer) with our community nursing service, or a health/social care professional wishing to refer a patient at risk of emergency hospital admission, the At Home First service can be accessed via one single telephone number: 0333 405 3000.

For more information check out our advice leaflet by clicking on this link.

Additional information

Using the Population Health Risk Tool (winner of the Health Service Journal Patient Safety Award)

We have identified patients who:

  • Have not had face to face contact with CCS staff for a year

  • Not house bound

  • Not in a care home

  • Are 65 and over

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 – advising when to call 111 and when to call 999. 

The AHFc arrange and facilitate these meetings that take place virtually via teams using Ipad’s put into the care homes by CCS.

The At Home First Team facilitates and co-ordinates the GP Practice MDT’s 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.

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"Seen very quickly. The nurse was very understanding, approachable and empathetic"  - Luton community paediatrics