The HomeFirst service provides support to patients by Rapid Response intervention preventing admissions for acute conditions, and providing case management for patients with long term or complex conditions with the aim to remain at home rather than going into hospital. Nurses including mental health nurses, social workers, therapists and home carers work alongside GPs.
HomeFirst aims to provide the right care in the right place at the right time every time by:
- Improving patient experience by delivering integrated care
- Helping to reduce hospital admissions
- Increasing independent living in people's own homes
HomeFirst performs three functions:
Rapid Response: Responding to people in crisis within 60 minutes.
Health and social care staff will respond within 60 minutes to people in crisis, who without rapid intervention would otherwise need a hospital admission. Referrals to the service come from professionals involved in a patient's care, including GPs, ambulance staff and health and social care practitioners.
Case Management: Identifying people who are at risk of hospital admission.
The 'virtual ward' identifies people who are at risk of needing to go to hospital, triggering appropriate interventions to avoid admission. This is delivered using risk stratification. People at risk of an unplanned hospital admission are identified and discussed at a multi-disciplinary meeting where a joint decision on whether to refer them will be made.
If a referral is made, the person will be pro-actively case managed on the 'virtual ward' with a team of health and social care professionals working together to provide the most appropriate care for up to six weeks. This means that in many cases people who might otherwise be admitted to hospital will be cared for in a 'virtual ward' in their own homes.
In-reach Support: Helping people regain independence following hospital admission.
The third function facilitates early discharge from hospital for those patients who can be supported at home with the help of health and social care; helping people to regain as much independence as possible following a hospital stay.
You can read about Marie's experience of HomeFirst in the patient experience section.
HomeFirst Lower Lea Valley Service information poster
Contact the Service
Lower Lea Valley Homefirst
Broxbourne Borough Council Level 3
Bishops College
Cheshunt
EN8 9XQ
Telephone: 01992 785612
Opening Times: 8am-6:30pm, every day
HomeFirst is an integrated model of care that supports older people with long term or complex conditions to remain at home rather than going into hospital. It brings together health and social care partners with a shared commitment to improving the health and wellbeing of the people of East and North Hertfordshire.
Once referred to HomeFirst, the team will contact the patient to arrange a suitable time to visit them in their home. If the patient's needs are urgent the team will aim to visit within the hour. During the visit the team will carry out a full assessment of health and social care needs and together with the patient and their carer develop a care plan that meets their needs.
Following assessment, the professional will determine if it is suitable for the patient to be managed on the rapid response caseload and draw up an individual care plan to meet the needs. The care plan will address all physical and mental health and social care needs and the team will support patients on the rapid response caseload for up to seven days. The case will be discussed at the weekly MDT meeting and the patient’s GP will be kept informed.
The team works collaboratively with other agencies to achieve the best outcomes for patients.
If the patient is deemed unsuitable to be managed by the service the team will arrange the appropriate onward referral.
HomeFirst supports older people with long term or complex conditions to remain at home rather than going into hospital.
A holistic assessment will be undertaken and the patient's needs identified and agreed.
Following assessment, the professional will determine if it is suitable for the patient to be managed on the rapid response caseload and draw up an individual care plan to meet the needs. The care plan will address all physical and mental health and social care needs and the team will support patients on the rapid response caseload for up to seven days.
The case will be discussed at the weekly MDT meeting and the patient’s GP will be kept informed. The team works collaboratively with other agencies to achieve the best outcomes for patients.
If the patient is deemed unsuitable to be managed by the service the team will arrange the appropriate onward referral.
Patients will need to be referred into the service by their GP, Ambulance service, A&E or other health or social care professional.
Referral form
If you would like to share your story, please contact the Patient Experience team on 01707 388036 or email pals.hchs@nhs.net.
We would also love to hear about your experience on our service, please complete a survey by clicking here.
Case study: Marie (aged 76)
Marie has always been extremely active and outgoing, working for most of her life. Before her illness she was doing an exercise class once a week, Knit and Natter group and going to the theatre with friends. Her husband died four years ago, they had been married 54 years. Marie takes up the story:
I was in hospital with a blockage in an artery. I had an angioplasty but was getting a lot of pain. Getting up was painful. It felt like hot sharp needles as you put your foot to the ground. All the blood’s going down past your ulcer and it’s very painful. But once the blood got there and I had a couple of paracetamol and it settled down I was able to put it to the ground.
The HomeFirst people have been wonderful. They’re all such a happy bunch, right from the first matron through all of the nurses, they’ve all been such jolly people and very kind. I can’t speak highly enough of them, they’ve been wonderful. They’ve definitely kept me out of hospital. My son and daughter wanted me to go back in but Emma said ‘let’s try HomeFirst’ I was delighted when the matron came and sorted it all out the very next day. I think HomeFirst is wonderful and I think everyone should use it.
Kerry Anne, Marie’s daughter
Mum was in so much pain my brother and I decided ‘that’s it, she can’t stay at home any longer’……but Mum really did not want to go into hospital. I took her to the doctors in the afternoon and we were going to say ‘we want her to go back into hospital’. But after Emma [the nurse] had dressed her leg she told us about HomeFirst. It’s instead of going into hospital. So we thought we’d try that to see if she could get the care she needed at home…and that’s why we had HomeFirst in. We didn’t leave the doctor’s surgery until 5.30pm and by the following morning at 11am the nurses were here.
Having HomeFirst has been brilliant. I live in Birmingham and spent four weeks with Mum. My daughter, Marie’s granddaughter, came down from Birmingham as well. My brother lives in Harlow but he works all week. I don’t work, so that’s why I came down. I was able to go home feeling confident that Mum was going to be OK. I couldn’t have gone without knowing exactly what care she was going to get. It gave us peace of mind knowing somebody was there for her.
It has worked so well and mum is much happier. She had all the things she needed like the Zimmer, the trolley, even a hospital bed with a special mattress because of the sores on her bottom. In hospital she told me she had to wait two and half hours for a nurse to have time to bring her a painkiller in the middle of the night. At home she can have them at the side of her bed. The reason I wanted something like this for mum when she came out of hospital was that she couldn’t look after herself. She was on a lot of medication, strong painkillers and she wasn't steady on her feet. If she needs more help Stepan can organize it but if she doesn’t then it can be taken away……and we didn’t have to wait months and months and months for all this to be put into place. She came home from that doctor’s appointment and next day nurses came round to dress her leg and talk to us about things – it’s been brilliant.
Stepan, Senior Practitioner
Marie was extremely pro-active…she wanted to get her life back. As Senior Practitioner I was able to take a holistic approach to her situation. What her family needed most was reassurance that she would be well cared for when they had to go home. We were able to demonstrate to them over the first few days that she would get all the care and support she needed, for as long as she needed it, to help her get back on her feet. Enablement carers encouraged Marie to keep her spirits up with the promise that she would be able to get back to doing all the things she used to enjoy. They encouraged her to help herself and to become self-sufficient again.
Marie was a very active patient and keen to get better. She is now no longer in need of carers, but is comfortable in the knowledge that if she were to need them again her GP would be able to refer her and we would respond as quickly as we did before. Home First succeeds in keeping patients in their own homes and out of hospital and in the long term saves money too.
Roshni, Physiotherapist
Marie had lost all confidence in walking because of the pain from her ulcers. We gave her two sticks and exercises to stretch her calves. She was soon able to get her heel down flat on the floor and her gait improved, giving her more confidence in walking. We encouraged her to walk further and for longer and recently have been walking her outdoors.
She is doing really well and we’re hoping to get her back in her car and driving to her many social activities again. Her functionality is back to its baseline now, so she doesn’t need carers, and that’s largely down to her dedication and determination in working with us to improve her situation.
It’s been a pleasure working with Marie. Seeing her through from the beginning when she was really struggling to walk and seeing her now, able to get out into the sunshine, is so very rewarding. Her personality is brighter and she can see a bright future ahead.
HomeFirst works really well with patients like Marie, but sadly many potential patients just don’t know this kind of service is available to keep them in their own homes and out of hospital.
Claire, Community Matron
Marie started out as a Rapid Response patient, which means we got to her within a very short timescale and carried out her assessment. I did an overview of her general health and wellbeing to identify her problems and then got other members of the team involved. Her main issue was a painful leg ulcer so we were fairly swiftly able to give her pain control and wound care. We also arranged for a hospital bed so that she could sleep more comfortably to relieve her pain at night.
HomeFirst is a joined up team. We see patients quickly and identify their needs to get on top of their problems. We are able to assess patients together and talk to one another rather than sending emails or voice messages. This is the great advantage in getting things done quickly.
