NHS Calderdale and Greater Huddersfield CCGs: Seamless Home from Hospital Service

The Seamless Home from Hospital Service (SHFH) provides a service to individuals to avoid admission and those being discharged: • The service to patients avoiding admission is offered as part of the integrated admission avoidance service, in conjunction with the Hospital Avoidance Teams (HAT). These patients will have presented at A&E at Calderdale and Huddersfield NHS Foundation Trust (CHFT). Clinical staff will have determined no clinical reason to admit the person to an inpatient ward but the patient is frail or vulnerable and needs additional support to ensure their safety and wellbeing to return home. • Patients being discharged will have been inpatients at CHFT or an associated intermediate care facility. Patients will be medically fit for discharge however may be frail or vulnerable and need additional support to ensure their safety and well-being going home. The service will contribute to the delivery of Calderdale and Greater Huddersfield CCG’s objectives of promoting health and well-being, and commissioning and providing the best possible care for patients. The aims of the service are to contribute to a reduction in avoidable hospital admissions and delayed transfers of care. Avoidable admissions include admissions from A&E for non-clinical reasons and readmission's after discharge. Days/hours of operation: On weekdays the SHFH booking line is available 9 a.m.-7 p.m., offering transport from hospital 10 a.m.-8 p.m. and support at home 10.30 a.m.-9 p.m. On weekends and bank holidays the SHFH booking line is available 11 a.m.-6 p.m., offering transport from hospital 11 a.m.-6 p.m. and support at home 11 a.m.-6 p.m. Referral criteria and sources: • The service shall be made available to frail and vulnerable adults (16 years plus) resident/registered with a GP in Calderdale and Greater Huddersfield CCG areas. • Referrals will be accepted from any discharge coordinator, clinician or support staff acting on behalf of a clinician, HAT team member or hospital social worker based at CRH, HRI or Intermediate Care. • Patients will be collected from any location at CRH, HRI or Intermediate Care.