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Helping people to stay in their own home

We know that people don’t want to go to hospital unless they really have to. Through helping people to stay at home and avoid being admitted to hospital, or helping them to get home as soon as they are medically well enough to do so, we can support them to get well in a familiar setting, as well as reduce the pressure on hospital services.

To allow ambulances to prioritise those calls who need immediate, emergency care such as responding to heart attacks or strokes, we’ve put in new services which are able to respond to those times where people need to a clinician to come to their home urgently, but it’s not an immediate, life-threatening emergency. This includes people who have had a fall, worsening infections, urgent equipment needs, new confusion and more. These services are able to support with the immediate need, but also identify any other issues and help to link in other support which the patient might need. 

Some services allow people to call them direct (self-referral), while others will refer patients via 111 or via their GP. To further support ambulances, some people who call 999 may be referred directly to these services.

New technology means that there are also new ways of keeping people safe in their own homes with clinical monitoring, or in their usual place of residence such as a care home. This means clinicians can spot any changes in a patient’s condition quickly even when they’re not there with them and address the problem before it becomes worse.

This means that patients can leave hospital more quickly, into the care of a “virtual” team who can continue to monitor them closely.

You can find out more about some of the services we offer by clicking on them below:

The Urgent Community Response service provides urgent support, seven days a week with the aim of preventing unnecessary hospital admissions. The service provides an alternative to an ambulance call out or attendance to hospital for people with an urgent or deterioration in their health or functional ability. The service is provided within patients’ home environment, to ensure a timely assessment and appropriate intervention.
The service offers a crisis response within 2-hours which focuses on supporting patients who are worried that they may have a new infection, are struggling with a flare up of a long-term condition, or whose health has generally deteriorated. A full assessment of the patient’s needs is completed. The service also offers a reablement response; a 24-48 hours response, focused on promoting and maximising independence, to allow people to remain in their own home following an illness or, in some areas, hospital admission.
The aim of the service is to provide care closer to home, which evidence shows is a patients first choice and can contribute to better health outcomes.
The service is provided by a multi-skilled team made up of a range of healthcare professionals. This varies between areas, but some examples of the roles are:

  • Advanced Clinical Practitioners
  • Clinical Practitioners
  • Nurses
  • Therapists
  • Healthcare Support Workers

Where appropriate, the UCR team will work with a range of other professionals involved in the patient’s care, such as their GP or hospital consultant, to ensure they receive the most appropriate treatment for their needs.
Any healthcare professional can refer into the UCR team including:

  • GPs
  • care homes
  • 111 (Patients and carers can self-refer to the UCR service, by calling 111)
  • West Midlands Ambulance Service
  • mental health services
  • community-based health and social care services
  • same-day emergency care (SDEC)

Find out more about the Coventry Urgent Community Response services here.

A great number of calls the ambulance service receives that are classed as urgent but not life-threatening are for falls with no injuries. In most cases, the person who has fallen does need to be assessed but this doesn’t have to be in hospital. 

Following a successful pilot in Warwickshire North, a service has been rolled out across to Rugby and South Warwickshire to respond to these calls within two hours, freeing up ambulances to respond to life-threatening emergencies. 

The falls assist service mainly assess and treats people aged 70 and over. Once assessed, follow-up can be arranged if needed.  

People who have fallen at home will be referred into the service by NHS111 or 999 services, so if you or a family member have fallen, please call NHS111 first. 

A pioneering GP-led paramedic scheme in Coventry and Rugby is helping to keep hundreds of patients out of hospital. Fully-trained paramedics are alerted by participating GP practices and see people in their own homes on the same day, dealing with illness and other issues which could otherwise lead to 999 calls. 

The Paramedic Acute Visiting Service (PAVS) was set up in 2019 by the Coventry and Rugby GP Alliance to support primary care – easing pressure on general practices lacking the resources to do their own home visits. 
PAVS operates every weekday. A paramedic booking is initiated by a practice after triaging the patient. An administrator then manages where the paramedics go, to minimise unnecessary travel time. 

Respiratory at home provides remote monitoring of people with respiratory conditions. It is a joint service provided by GPs, community care and the hospitals. 

People using the service are given a pulse oximeter to allow their blood oxygen levels to be monitored remotely. 
The pulse oximeter is put on the tip of the finger and by regularly monitoring oxygen levels with this, it can be easier to spot if respiratory symptoms are getting worse and identify if someone needs treatment or support.  

If the readings show oxygen levels are starting to fall, the patient can be referred by the GP to the hospital to get the treatment they need early. Patients receive two phone calls a day; one to collect all the readings and another from a doctor to advise on next steps based on the data.

We want to help care home residents avoid unnecessary ambulance journeys and visits to Emergency Departments. To help support their carers there are a number of tools we have put in place. One of these is remote monitoring using a remote monitoring tool called Docobo. This monitors residents, firstly to establish a baseline for their normal condition. If residents become unwell, observations can be shared with their GP who can then decide what action is needed. 

For carers, this means they don’t have to spend time on the phone to the GP if they have concerns about a resident’s health and for GPs, they can make an informed decisions without visiting the care home.