HNY Policy and Pathway Repository - Humber

The CHCP Frailty Hospital at home (H@H) (Virtual Ward) provides acute medical care to patients living with frailty in the comfort of their own homes (including care homes), as an alternative to traditional hospital admission, allowing patients to receive high-quality care without the need for an extended acute hospital stay.

Through the H@H multidisciplinary teams—including doctors, nurses, and allied health professionals—coordinate and manage patient care supported by a combination of face to face home visits, telehealth consultations and wearable devices. The approach aims to improve patient outcomes, enhance satisfaction, and reduce hospital related deconditioning and harm by offering safe and effective medical care.

Interventions available include once daily intravenous antibiotics, bolus intravenous furosemide and subcutaneous furosemide, subcutaneous fluids, as well as close monitoring and titration of medications.  

No Red Flags Listed

Inclusion criteria:

• Clinical Frailty Score 5 or more
• Patient meets DOT criteria (see below – additional resources ) 
• Registered with a Hull or East Riding of Yorkshire GP practice
• Suitable to be supported within their normal place of residence or a community bedded unit
• Has urgent or emerging care needs for higher acuity care to manage intercurrent illness/frailty/exacerbation in underlying long-term condition.
• May have high degree of prognostic uncertainty (person might be deemed to be within last 12 months of life- EOL) and needs period of ongoing support and monitoring to establish preferences and personalised advanced care planning goals before transition to palliative and end of life care services
• Clinical judgement should be used where a person is living with dementia or has limited capacity including a learning disability, this should not exclude admission to the service.

Exclusion criteria

• Experiencing a mental health crisis and requires referral/assessment by a specialist mental health team that cannot be supported in the community
• Another service is suitable and available to support the needs of the patient within a safe time frame
• If it is not safe for a person to receive support and treatment in their own home, care home or community bedded unit and there is not a suitable alternative setting (i.e., local family, short term placements, etc.)
• Those who are not resident in the area
• Requires emergency care interventions/ has treatment escalation needs that can only be offered in secondary care hospital environment (and these are appropriate for and wanted by the patient)

Additional resources

CHCP_Virtual_ward_patient_leaflet.pdf

It may be helpful to think of the acronym DOT when considering whether a patient is suitable for Frailty H@H:

‘DOT’ guidance:

Drink – can they get a    drink on their own, or do they have someone who can help them?

Once a day – can they manage with a visit from the team only once a day?

Toilet – Can they manage to get to the toilet on their own or do they have someone to support them?

Referral sources:

• Referrals are accepted from any healthcare or social care professional involved in the care of the patient.  All referrals must be made directly by the healthcare/social care professional. 
• Referrals for either “step ups” or “step downs” are accepted from local acute hospital organisations (local pathway arrangements apply)

We are unable to accept referrals made by GP administrative staff.

Referral criteria/Information:

The service is open for referrals (not admissions) Monday to Friday   between 8am and 6pm. 

• Referrals are accepted via the Urgent Community Response (UCR) line: 01482 247110.
• Admissions are generally Monday–Friday and preferably before 14:00 to allow same-day assessment and intervention.
• Referrals may be accepted up to 18:00 on a case-by-case basis, where it is safe for the person to remain at home overnight until the admissions team can pick up the next morning).