Information summary - patient cohort

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 patient cohorts. 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.  

 

What are your inclusion/exclusion criteria?

Aberdeen City

Inclusion:

• Patients with frailty presenting and with an acute medical issue  
• No age specification  
• Outpatient Parenteral Antibiotic Therapy (OPAT) cohort, and  
• Five palliative care beds.  

Dundee City

Inclusion: 

• Patients with frailty who are at imminent risk of hospital admission or whose health has or is at risk of deterioration.   
• Patients who require geriatrician assessment, care identified through the advanced nurse practitioner (ANP) or nursing assessment. 

Exclusion: 

• Acute abdominal issues 
• Chest pain 
• Symptoms of stroke or transient ischaemic attack (TIA) 
• Haemorrhage 
• Suspected sepsis 
• NEWS score greater than seven, and 
• End of life.
   

Glasgow City

Inclusion: 

• Over 65 years of age 
• Acute functional decline due to underlying health conditions 
• Acute complex multiple medical problems 
• Frailty – acute decline of uncertain cause 
• Exacerbations such as COPD, asthma or heart failure 
• High risk of hospital admission or deterioration 
• Acutely unwell nursing or care home patient with any of these presentations 
• Severe infections such as pneumonia, urinary tract infection (UTI) or cellulitis 
• Delirium 
• Recurrent falls with no injury likely due to underlying acute illness 
• Dehydration 
• UTI with multi resistant organisms requiring intravenous (IV) antibiotics 
• Acute presentation of suspected advanced malignancy, and 
• COVID 

Exclusion: 

• Stroke/TIA 
• Cardiac Event 
• Fractures needing acute assessment and possible surgical management, for example, hips 
• Gastrointestinal (GI) bleed 
• Acute abdomen 
• Deep vein thrombosis (DVT) 
• Social care crisis 
• Diabetic Ketoacidosis, and 
• Head injury.
  
  

Fife

Inclusion:

• They are registered with a GP in Fife. 
• It is safe for the patient to be managed in their own home; they can be left alone overnight.  
• Generally, H@H patients are house bound. 
• The service does not have a minimum age limit for example, over 65s. Although most patients are over 65, the services can take younger patients, for example, people with learning difficulties and, or long-term conditions.  
• There are also clinical criteria for the service. 
  
  

Forth Valley

Older people with frailty with acute needs (needing hospital admission). 

Moray

We do not have exclusion criteria at the moment as we are keen not to have criteria so as not to restrict service.  

The main inclusion criteria are older people with frailty. 

Lanarkshire

Patient Criteria*: 

• Over 65, with clinical/medical needs requiring hospital admission 
• Frail elderly, and 
• All nursing home patients 

Conditions Frequently Managed By H@H: 

• Respiratory and influenza like illnesses 
• Urinary tract infections and other infections requiring IV fluids, IV antibiotics or Blood Transfusions 
• Frailty  
• Deep vein thrombosis (DVT) 
• Exacerbation of COPD 
• Exacerbation of cardiac failure 
• Atrial Fibrillation 
• Falls, and  
• Delirium 
  

*All of the above are assessed on a case by case basis for admission to our service, and having one of the above symptoms or conditions does not necessarily automatically admit patients to our service. 

Exclusion Criteria**: 

• Patient condition not otherwise requiring hospital level care 
• Acute Coronary Syndrome  
• Stroke 
• Acute Surgical or Orthopaedic Crisis, and  
• Social issues 

**The above list is an accurate guide but is not exhaustive, referrals are screened as appropriate on a case by case basis. 

 

Perth and Kinross

Inclusion criteria: 

• Resident in Perth City locality, greater than or equal to 65 years of age 
• Delirium 
• Frequent falls  
• Acute reduction in mobility  
• Poly-pharmacy 
• Unexplained functional decline or frailty 
• Symptom management, and  
• Acute exacerbation of an existing long-term condition  

Exclusion criteria: 

• Acute Coronary Syndrome  
• Stroke  
• Mental Health Crisis  
• Haemodynamically unstable patients 
• Presentations requiring IV therapy (team is supporting OPAT while awaiting the full model as described below) 
• Patients not requiring Hospital Level Care, and 
• Acute Surgical or Orthopaedic Crisis. 

While establishing the service the team are engaged with activity across the three localities within Perth and Kinross to support early discharge and hospital admission avoidance by working with the Locality Integrated Care Service (LiNCS), Community Rehab and acute colleagues as well as OPAT that is not necessarily H@H specific but working to support wider system pressures within their professional capacity. 

Lothian

Inclusion: 

• Resident aged 65 and over (patients under 65 may be accepted if residing in nursing or care home settings or have advanced disabilities).  
• Preventing admission for acute medical cause that would otherwise require hospital admission. 
• Personal care requirements that can be met in the community (safe at home, self-caring or existing packages of care or supporting family).
  

Exclusion: 

• Cardiac chest pain  
• Acute stroke 
• Acute Asthma  
• Suspected Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) if hospital pathway appropriate for patient 
• Trauma/suspected fracture(s) 
• Acute surgical emergencies, including abdominal pain 
• Patient or family unwilling to stay at home 
• More than two litres oxygen requirement, and  
• Social issues only. 

West Lothian do not have an age criteria, but patients require to reside within West Lothian and agree to H@H input. 

Western Isles

Inclusion: 

• Adults (over 16 years old), and 
• Patients with an acute medical need. 

Exclusion: 

• Needing social care (though health and social care worker help provide some personal care now). 
• Needing antibiotics more than twice a day. The team can sometimes be flexible on this, depending on factors such as geography. 

 

What is the bed capacity of your service? 

Aberdeen City 

30

 
Dundee City 

We do not have an identified bed capacity – this will be assessed over time. 

 
Glasgow City 

• As at April 2022: 10 beds. 
• With capacity to grow to 25 beds. We have milestones for this, will take through governance structure to discuss this and agree when to increase to next level of capacity.  
  
  

Fife 

This is variable dependent on a number of criteria, currently approximately 33 virtual beds with ongoing plans to increase.

Forth Valley 

When fully up and running 25. Patients are scored based on acuity, and geography to help define capacity. On a daily basis capacity sent to community and acute. 

 
Moray  

• There is currently no strict definition of bed capacity. 
• The team may advise on many patients with lower acuity but a general guide might be 10-20 patients per week with higher acuity. Only a small proportion of these would have H@H level of needs.  
• Advanced Care of Elderly Practitioner is used to identify frailty earlier, ensuring that people end up in the right place. 

 
Lanarkshire 

78 beds across four teams. One hub on each of the three acute sites plus one early supported discharge “step down” hub. 

 
Perth and Kinross 

The initial plan is to enable a five bed community based ward to support testing of the new model and enable rapid evaluation of capacity of the service. 

 
Lothian 

The bed capacity within each team is dependent on factors such as the acuity and interventions required of each patient on the caseload. It is monitored on a daily basis using the acuity tool. 

 
Western Isles 

Nine (flexing to 12)

 

How do you measure/track the acuity of your patients?

Aberdeen City 

As of 10 October we will be using an acuity tool which was developed by NHS Fife.  

Dundee City 

We are trialing use of an acuity and dependency tool which is based on the Fife tool. It is being adapted in real time as part of service development.

Glasgow City 

• Individual clinical assessment against criteria and interventions is required. 
• Patient’s Rockwood score is identified pre-admission. It is not scored over time. 
  
  

Fife 

Use the Fife Acuity tool. Also have a RAG status for each patient to help with adverse situations.

 

Forth Valley  

We have an acuity score from one to four which is based on the number of visits required each day. 

Moray  

We manage this using regular meetings and catch-ups, including joint care with GPs. We do not currently have any formal tools for measuring this.  

Lanarkshire

• Patient NEWS score 
• Monitor observations, and  
• Discussion at daily virtual ward rounds.
   

Perth and Kinross 

• National Early Warning Score (NEWS) 
• Rockwood Frailty Score, and 
• Acuity and Dependency Tool.
    

Lothian 

We use an acuity tool developed by all the NHS Lothian H@H teams. This takes into account the clinical condition of the patient, the number of visits they require and any interventions (for example IV therapy). It also takes into account distance travelled and the staffing capacity. 

Western Isles

• This isn’t something that is in place at the moment. 
• H@H is often used for step down. 
• The new band 7 nurse should help with the development of this. 

 

What other ways do you measure capacity in your service?

Aberdeen City 

• Professional judgement, and 
• RAG status for staff numbers
   

Dundee City 

Length of stay.

Glasgow City 

• Number of visits required per patient. 
• Interventions associated with patient. 
  
  

Fife 

During 2021, we developed and implemented new systems to support and enhance how we determine and report the three H@H teams and Fife wide service capacity. This is a comprehensive approach that encompasses the following fundamental “CRAGS” information: 

• Current Caseload 
• Referrals - number of new received today  
• Acuity and dependency of patient’s 
• Geography/travel zones RAG status  
• Staffing RAG status  

The individual CRAGS measures are all interconnected in terms of determining overall capacity and it’s important that these are considered collectively.  

The team have developed and shared a presentation on our acuity and dependency and capacity measures which is available on the MS Teams H@H community.  

Fife Hospital at Home service have also developed an Operational Pressures Escalation levels tool to support capacity. This is based on the CRAGS information above.  

Forth Valley 

• Geography 
• Dependency, and 
• Available bed
  
  

Lanarkshire 

• Complete daily safety brief including complexity and staffing.  
• Weighing up of workload, staffing, patient acuity and staff complement.
   

Perth and Kinross 

Safety briefs every morning to determine patient acuity and therefore safe staffing levels. 

Lothian 

Senior clinical judgement and discussion in light of above. 

Edinburgh  

Patients declined due to capacity are recorded and review of these patients is planned. 

Western Isles 

Capacity of the service is measured by looking at the geography of patients, severity of illness and the number of visits required to patients. If there is any opportunity for flexibility, whilst keeping safety as the priority, the team will try to accommodate patients when referred.