At Home First, Luton

What is the At Home First programme for adults?

We want to help people maintain their independence and dignity through the provision of co-ordinated, seamless health and social care in their own homes.

As the Co-ordinating Provider Organisation, we are working with community based NHS and social care organisations across Luton to deliver At Home First integrated services to adults.  These services ‘wrap around’ patients at high risk of emergency hospital admission, enabling them  to remain (and be treated) in their own homes where this is clinically appropriate.     

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.

GPs can also continue to use existing contacts for Community Matrons and Care Co-ordinators

Click here for our Information Leaflet

What is At Home First?

At Home First incorporates two innovative services:  Intensive Case Management and Integrated Rapid Response Services summarised in the picture below.

Click here to print out a copy of the above picture.

In summary:  

  • Intensive Case Management: our Community Matrons, work closely with GPs and service users, to  develop home based Personalised Care and Support Plans which set out the co-ordinated social, primary, community, and mental health services that people need.  These plans will typically cover periods of 30-90 days.  Multi-disciplinary (MDT) Care Co-ordinators will support Community Matrons develop these plans through the provision of administrative support and by arranging monthly MDT reviews held in GP practices.

    Click here for details of our which services and professionals could be involved in the delivery of Personalised Care and Support Plans.

    Click here for a more detailed explanation of the intensive case management referral pathway 
  • At Home First Integrated Rapid Response service (9.00 am – 5.00 pm):  co-ordinated nursing, social care, therapy and reablement services will stabilise patients in crisis supporting them to remain at home.  Daily multi-disciplinary team reviews will take place and after a period of 72 hours patients who require ongoing care will transfer to the intensive case management service (see above) or, if required, be transferred to hospital or an alternative community setting e.g. nursing or residential home.   In addition, our At Home First Nursing Rapid Response Service provides services 24 hours a day, seven days a week.

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