The aim of the service is to prevent patients from being admitted to hospital if they don’t need to be and ensure that if patients do need to have a stay in hospital, that they are discharged as soon as possible to continue their care at home.
The team is made up of a GP, nurses, occupational therapists, physiotherapists, support staff, social workers, primary care mental health nurse and a handyman.
Staff within the team work for different organisations, such as the NHS and the London Borough of Hounslow, but work together to ensure that patients receive the right care from the right people at the right time.
Although the service works with patients of all ages, the majority of patients who use the service tend to be elderly as this particular patient group is more likely to have multiple health concerns, reduced mobility, or have frequent falls and require rehabilitation.
With the breadth of healthcare professionals within the team - patients benefit from receiving a comprehensive assessment and package of intervention which looks at all parts of their ability to stay at home, such as their health, social needs and mental health needs.
The team can be involved with a patient for up to 7 days and during this time plans will be made with the patient to ensure all ongoing needs are supported by working with and referring to other community services such as community nursing and therapies, GP, social services.