Home to Assess and Rapid Community Response Team

The service can include:

• Post-op wound checks
• Suture/clip removal
• Short term monitoring following discharge i.e. BP monitoring depending on findings e.g. pre-op/post-op BP Hyper/Hypotension monitoring over the post 72 hr discharge
• Short term bladder/bowel intervention i.e. initial assessment of catheter patients not known to Community Nursing prior to Trial without Catheter (TWOC) patients
• Monitoring people with long term conditions experiencing exacerbations whilst antibiotics and clinical observations are monitored and/or use of nebulised medications
• People experiencing confusion whilst suffering and being treated for UTIs and require an assessment and follow up treatment in their own homes. The Team consists of Registered Nurses,  Physiotherapists, Occupational Therapists, Social Workers, Assessment Reablement Officers and Technical Instructors, who work together to provide short-term support and rehabilitation in the persons home over a 72 hr period

We have access to:

• Specialist services and equipment
• ‘Transfer to Assess’ (T2A) beds for people requiring 24-hour emergency care and a management plan for health or social care, or both and also a period of assessment from therapists following a fall for example. (This service is not for people requiring respite, unless required due to an emergency situation with the main carer)

For general queries email: wcnt.rapid@nhs.net

Referral Process

Referrals from Wirral University Hospitals NHS Foundation Trust (WUTH) for Home First Services within the SPARCS Integrated Gateway, is through the digital discharge process via WUTH.  Referrals for the Rapid Response Service and out of area patients can be referred via SPA on 0151 514 2222 option 2.

What happens after referral?

• Patients will be triaged by the SPARCS Duty Triage team, who consist of a Registered Nurse, Therapist, Social Worker, Mental Health Practitioner and Assessment Reablement Officer
• Duty Triage team will review clinical history and information available including therapy/nursing goals. Depending on speciality named in referral following triage, further referrals maybe required and instigated to the wider Multi-disciplinary team.  If the referral is not appropriate for SPARCS, the team will forward this referral to the most appropriate service and inform referrer
• Patients will be assessed in their own home on either the same day of discharge or the following day depending on discharge time from hospital, depending on information provided within referral and then priority following triage
• A management plan and appropriate level of care will be put in place – the most appropriate clinician will liaise with GP/wider MDT where appropriate
• The persons named GP/wider MDT will receive a discharge summary with any relevant care plan/package that has been identified

Who is suitable for referral?

• People that are returning to their own homes following discharge who still require a period of rehabilitation with short term goals, or require a full assessment in their own homes for any equipment or low level adaptations that they may require
• Must be 18 years of age or over and living at home in the community and who are registered with a Wirral GP

Who is unsuitable for referral?

• Patients with CVA/TIA, hematemesis, severe chest or abdominal pain
• Referrals for people with long term conditions that can be effectively managed by social or health care services
• Any long-term Therapy conditions and adaptations – these are managed by Adult Social Care Occupational Therapy Team
• People requiring respite or end of life care

Consent must be gained from the person by the referring professional prior to referral

Part of Single Point of Access and Referral to Community Services Integrated Gateway Team (SPARCS)