Information summary - pathways

All Hospital at Home (H@H) services in Scotland operate in a unique way, while following the key elements laid out in the Guiding Principles document 

For a better understanding of what this means for the different services, we have pulled together the relevant information about their pathways. The data are taken from the information sheets that were provided by the services, originally in October 2022.  

The information in this document was accurate at the time of publication but as services evolve, the information will change. This document will be reviewed and updated annually.  

 

Who can refer to your H@H service and how do services refer (including SAS)?


Aberdeen City

  • GPs 
  • City visiting team (ANP led in primary care) 
  • Frailty pathway 
  • Acute medical initial assessment
  • Emergency Department, and  
  • Direct nursing home referrals 


Dundee City

  • GPs 
  • Community based ANPs 
  • Acute Frailty Team 
  • Scottish Ambulance Service (SAS), and 
  • Acute Medical Unit (AMU) Consultants 

Glasgow City

  • Acute – Assessment Unit. Uptake was initially slow from this setting. 
  • GPs – Within scope of test of change – increasing in September as part of roll out of service. 
  • Currently in the south of the city, looking to expand to the north-west of the city.
     

Fife

  • GPs 
  • NPs and ANPs within GP practices as long as they have linked with GPs 
  • ANPs in care homes  
  • Referrals from acute services come through the Flow and Navigation HUB. They could be referrals from the front door, step downs or wards.  
  • There is a Scottish Ambulance Service (SAS) pathway and process which is currently progressing through a test of change and links with the Flow and Navigation centre in Victoria Hospital Kirkcaldy.
     

Forth Valley

  • GPs (senior decision maker) or ANPs, as long as they are a registered clinician. 
  • We are liaising with the paramedic lead, who will accept patients between 8am and 6pm. 
  • The SAS pathway is now live so SAS can refer. 


Moray

  • Use three pods: inpatient, front door, and community 
    • Inpatient: specific Care of the Elderly (CoE) beds, liaise with other services within Dr Gray’s Hospital. 
    • Front door: Emergency Department (ED) clinicians, front door therapy team, acute medical admission unit, clinicians, also includes email for all over 80s not in ED. Proactively looking for referrals through this route.  
    • Community: regular (monthly) virtual meetings with five or six GP surgeries, covering approximately three quarters of the population of Moray. We receive direct referrals through TRAK, email for more urgent ones and D2A referrals, though most referrals are from the GP practices. Currently promoting the phone line as direct GP contact. 


Lanarkshire

  • SAS and GP, ED (Admission Avoidance): refer via the Flow Navigation Centre (FNC), can also call H@H Hubs directly for advice. 
  • Referrals from Community Teams (such as District Nursing) – call direct to H@H Hub. 
  • Ward Step Downs (early supported discharge) – call to hub to check that the referral is suitable and check that we have capacity then complete a Workbench referral on Trakcare.
     

Perth and Kinross

  • The team are currently pulling patients in to be supported within their scope of practice, taking a community in reach approach to hospital as well as supporting the community teams when able. 
  • Not operational as a full Hospital at Home model at present due to awaiting confirmation of medical cover. 
  • In the future, the service will accept referrals from Hospital Discharge Teams, community services (LiNCS, SAS, ANPs), GPs; referrals should be made by phoning the H@H Service phone number. H@H co-ordinator will discuss it with the referrer and triage.  
     

Lothian

Midlothian 

  • GPs 
  • A&E 
  • Hospital wards 
  • Heart Failure Team 
  • CRT 
  • SAS, and 
  • GP out of hours (if the patient is in a care home or known to the team in the past three months). 

Edinburgh 

  • GPs 
  • Community nurses 
  • SAS – refer via flow centre. Some limitations in Out of Hours (OOH) period 
  • ED 
  • Acute Medical Unit (AMU) 
  • Hospital wards, and 
  • Day hospital refer via nurse coordinator telephone. 

West Lothian 

Telephone referral to H@H Coordinator from: 

  • GPs 
  • Medical Assessment Unit 
  • A&E 
  • Hospital wards 
  • Frailty team 
  • Other community teams for example, palliative care, heart failure, and community nursing teams. 

Out of hours A&E can email referral to Inbox. 

 
East Lothian 

  • GPs 
  • A&E 
  • Wards 
  • SAS 
  • OOH GPs 
  • Care Home Team 
  • DNs 
  • Heart Failure nurse specialists, and 
  • PT/OT

Western Isles

  • Patients are referred from the hospital, the team use the daily morning meeting to assess which patients might be acceptable.  
  • Doctors will assess patients on arrival to hospital, with no referrals coming directly from GPs. 
  • Some of the patients in H@H are nearly ready for discharge from the inpatient ward but not for full discharge so are referred into H@H. 

 

Do you have a formal referral pathway with SAS?
 

Aberdeen City 

Have started a test of change for referrals. 

 
Dundee City 

No

 
Glasgow City 

Meeting at the end of August 2022 to commence discussions. There are two elements of a pathway with SAS: transporting patients for imaging and starting a pathway for referrals. This would be geographically limited at the moment 

 
Fife 

There is a SAS pathway and process which is currently progressing through a test of change and links with the Flow and Navigation centre in Victoria Hospital Kirkcaldy. 

 
Forth Valley 

Yes, when team are there between 08:00-20:00. 

 
Moray  

Not at the moment but there are plans to do this in future. 

 
Lanarkshire 

A flowchart was recently developed for use by SAS as part of a “Raising awareness” campaign for SAS Teams. SAS calls are directed to FNC. 

 
Perth and Kinross 

Not at present. Connections with SAS have been made and once the service is fully operational we will look to enable a formal referral pathway. 

 
Lothian 

Yes

 
Western Isles 

Not yet, have looked at it and work is in progress. 

 

Do you take referrals from care navigation hubs, and if so, what are the benefits and challenges?


Aberdeen City 

This is being developed in Aberdeen City at the moment 

Dundee City 

Referrals from care navigation hub are routed via Acute Frailty Team bleep holder, to date there have been very few referrals through this route. 


Glasgow City 

  • FNC as part of acute pathway is in development. 
  • Home first is at the early stages with FNC. 
  • It is part of the acute pathway but we have not fully engaged with it at the moment until more patients have been taken through that route. 


Fife 

Benefits:  

  • They go through a clinical triage which saves time for the H@H team.  
  • More appropriate referrals and therefore patients.  
  • It means H@H staff can focus on direct patient care and caseloads as spending less time triaging.  

Challenges: 

  • Not all staff having a good understanding of what the H@H service is.  
  • Processes not always followed properly.  
  • Communication can be difficult, people may not be in relevant meetings or read emails.
     

Forth Valley  

No but we are currently in conversation with the flow centre. We have had a few referrals from flow centres but they are not an official pathway. SAS pathway goes through the flow navigation because SAS wanted a single point of entry. 

Moray  

Not currently but maybe in future.  

Lanarkshire

FNC – Beneficial because they vet the referrals for us and if we are at capacity then they can signpost appropriately. They are also able to gather data on our behalf.  

Perth and Kinross 

Not at present. Could be explored in the future via the Flow Navigation Centre. 
 

Lothian 

Midlothian  

Yes 

Benefits: Reduced call handling. 

Challenges: Limited clinical information and reduced opportunity to redirect to alternative services.  

Edinburgh  

Yes 

Benefits: Frees up clinical time discussing these calls, assists with admin as admitted to expected ward, calls can be redirected by team from admission to alternatives to admission, GPs don’t need to be aware of all pathways themselves. 

Challenges: The flow centre call handlers are not clinically trained and have multiple pathways to follow, this means they often don’t follow pathway directly. Having to be available to answer the phone to give immediate answers can be challenging when there are other clinical responsibilities. 

West Lothian 

No, direct conversation with referrer allows H@H to triage referrals and maximise capacity. 

East Lothian 

Yes 

Benefits: Single point of contact for referrers. Telephone lines always staffed. Flow centre can check that the patient meets our criteria. 

Challenges: GPs don’t like it, they have to wait to get through. Majority of the time GPs don’t send formal referral information via SCI or email after referring GPs not contactable afterwards to ask questions. Makes triaging referrals and giving advice very challenging. Flow centre don’t always call us to say there has been a referral, so you have to constantly check just in case. Multiple referrals can come through even when you don’t have capacity. Difficult for flow to always access clinical staff in the team as no capacity for an office-based clinician. 


Western Isles

No

 

Does your service support early discharge from hospital? 

Aberdeen City 

Yes from geriatric assessment unit (GAU).  

Dundee City 

The Enhanced Care at Home Team (EC@H) supports patients on discharge. Patients in H@H have mainly nursing rather than medical needs. Transfer of care from inpatient to the EC@H geriatrician is not the norm but would be possible. 

Glasgow City 

There is an opportunity for ward referral as an agreed pathway but with limited numbers to date. 
 

Fife 

Yes

Forth Valley 

Yes, as well as admission avoidance. 

Moray  

We have accepted patients from ED, also from other areas as prompt geriatric reviews are available. Linking in to D2A would include early discharge. 


Lanarkshire 

Yes, we have a “Step down” element to our service which operates from the University Hospital Monklands hub. 

Perth and Kinross 

Yes

Lothian 

All H@H Teams support early discharge from hospital. The RAG status is updated by the H@H teams twice a day and shared at the hospital safety huddles via an MS Teams channel. It is also used by NHS Lothian’s Gold Command. 

Western Isles

Yes

To which service or professional are patients discharged to from your H@H service?


Aberdeen City 

  • Community adult assessment rehabilitation service (CAARS) 
  • GP, or 
  • District nurse (DN)

Dundee City 

  • GP 
  • Community Nursing 
  • Social Care 
  • Palliative care, including MacMillan nurses 
  • Heart Failure and Respiratory Specialist nurses  
  • Specialist outpatient clinics, and 
  • Inpatient care 


Glasgow City 

  • GP 
  • Referrals to Community Rehab 
  • Respiratory 
  • Home care 
  • DNs 
  • Heart failure, or 
  • Palliative care 


Fife 

The same as if they were an inpatient: follow up clinics, care homes, home care, therapy, for example.  

Forth Valley  

Back to the GP, community rehab or transferred to hospital. 

Moray  

Patients are already receiving support from other services as we are not a full H@H service.  

Lanarkshire

  • Back to GP Practice 
  • District nursing, or  
  • Other Community Rehab Teams
     

Perth and Kinross 

  • GPs 
  • Onward referrals to MDT 
  • Care Homes, or 
  • Health and Social Care Teams

Lothian 

Usually, their GP. Some may be escalated into hospital. Some may be discharged back to GP care but with ongoing input from services such as the Heart Failure Team or CRT for ongoing monitoring. 


Western Isles

Normally to their GP but patients may still have input from specialist services post-discharge. 

 

How do you access support from care services if someone needs a short-term package to avoid hospital admission?

Aberdeen City 

  • Service level agreement, or 
  • Daily huddle – enhanced community support huddle to raise care related needs. 

Dundee City 

A Social Care co-ordinator sits within the team. Short term social care has been commissioned specifically for this purpose though capacity has been severely limited. The provider for this is currently changing. 

Glasgow City 

  • Homecare pathway to start or increase packages of care. 
  • Referral to carer service for additional support, Glasgow City has a well-established care service to link with. 
  • Glasgow City has its own homecare provision. When expanding to other areas, that don’t have this, we may find challenges. 

Fife 

Fife are able to access short term packages of care. If there is reduced function due to acute illness then the team would involve colleagues in the intermediate care team who can provide up to four personal care visits daily.  

If longer term care is needed they go through the normal referral process for care at home. 

Forth Valley 

In the immediate phase health care support workers (HCSW) can support patients by providing care at home (at least a week). If there is a longer term care need we would refer a patient to social work. 

Moray  

It is hoped that by linking with Community Response Team we can integrate this. We are looking to connect more. The Community Response Team has three teams in three areas. 


Lanarkshire 

In most areas that we operate we have priority access to social care packages, staff complete a referral form or contact the social work department directly. There are a number of services becoming available at the moment like Home First and the Home Assessment Teams which provide interim care in a patients home until a social work care package can commence, we hope our H@H teams will be able to refer to these too. 

Perth and Kinross 

  • Liaise with Access Team at Social Work 
  • Cases have also been presented to the daily MDT LiNCS huddle

Lothian 

Midlothian  

We refer for this through Midlothian Single Point of Access. It is provided by the Rapid Response Team/Discharge to Assess Team carers. 

If very short term care is required, we do have Band 3 clinical support workers in the team who will provide personal care.  

Edinburgh  

If this is urgent we will discuss with Home First Practitioner at Flow Centre initially. If they are unavailable we may approach any current care provider or make a referral to social care (SC) directly. Our APP (currently on secondment) was able to assist with this work. We have on occasion referred to Hospital to Home team, who can bridge until a more permanent arrangement can be put in place. Routine referrals for packages of care are made via request for service on TRAK or telephone to SC direct.  

West Lothian 

Crisis care.  

East Lothian 

We complete a ‘request for service’ and the East Lothian flow team co-ordinate it. There is an Emergency Care Service but they are often at capacity and they also support hospital discharges who are waiting for formal packages of care. The majority of the time we cannot access care when we need it. 

Western Isles

This is an area that has not been developed as START often take on this role. A patient may be on a ward in the hospital for a couple of days for assessment before a care plan is put in place.