What is the Home Ward (Frailty) team

• The Home Ward team can help you stay at home, where you are most comfortable, by providing care if you are living with frailty (weaker and more vulnerable than others the same age).
• Helps avoid hospital admissions.
• Being cared for at home can improve the experience and outcome of your care by reducing any disruption to your life and the lives of your family and carers.
• Home Ward can support you by helping you return home quicker after a hospital visit, lowering the risk of reduced independence.
• The Home Ward will work alongside others involved in your care to ensure a plan is put in place.

A highly trained practitioner, such as a community matron or trainee community matron, will assess you. This may involve taking some blood or other samples.

They will ask you what matters most in order to create a care plan tailored to you. Family or caregivers are welcome to join you during this assessment.

If you have symptoms like breathlessness or swelling caused by heart issues, a heart failure specialist nurse might come and visit you.

Your care will be provided by a clinical team who will offer support through home visits, telephone calls and overnight care if needed.

Sometimes, you may need to go to the hospital for more specialist investigations or treatment, the Home Ward team will organise this for you. This is usually at St James’s Hospital. Depending on your results, you will normally come home the same day.

A community matron and trainee community matron will update you daily about when your next visit will be. You may also receive care from:

• a consultant geriatrician (medicine for older adults). Your case will be discussed with the Geriatrician in a multidisciplinary meeting rather than seeing you face to face
• community nurses and night service if appropriate
• heart failure specialist nurses
• pharmacists and pharmacy technicians
• physiotherapists and occupational therapists
• healthcare assistants
• other organisations and charities, for example, Age UK’s home comfort service

This can be a few days or weeks.

When to discharge you will be a joint decision between you and the Home Ward team.

We acknowledge that you may have questions about your care after leaving the home ward.

If you require additional support, we will direct you to the appropriate services. Otherwise, your GP will take charge of your ongoing care.

If appropriate, and with your consent, we can refer you to services like Age UK’s home comfort, Adult Social Services, therapy services, and the Neighbourhood team for ongoing support during your recovery under the Home Ward team.

The community matron or heart failure specialist nurse may have adjusted your medication during your stay on the home ward.

The home ward pharmacists will ask your GP to update your prescription. If you use a medication box (dosette box), the Home Ward team will ensure your medication is correct for future prescriptions.

We understand the crucial role that informal carers will play in supporting patients to be cared for safely at home. We will try our best to support you.

Carers will be involved in care and kept up to date as much as the patient wishes them to be. We will take into account any lasting power of attorney for health that may be in place, when patients are not able to make
decisions themselves.

More support for carers can be provided by Carers Leeds:

• Phone: 0113 246 8338
• Email: admin@carersleeds.org.uk

Go to A&E immediately or phone 999 if:

• you are so breathless that you are unable to say short sentences when resting
• your breathing has suddenly got worse
• coughing up blood
• you feel cold and sweaty with pale or blotchy skin
• you have a rash that looks like small bruises or bleeding under the skin which does not fade when you roll a glass over it
• you have chest pain
• you feel agitated, confused, faint or very drowsy
• you have stopped or are passing less urine than usual.

Ring the Home Ward team or 111 as soon as possible if, since you were last seen by the team:

• you are feeling gradually more unwell or more breathless
• you have difficulty breathing when you stand or move around
• you feel very weak, achy or tired
• you are feeling very dehydrated
• you are shaking or shivering

You may be improving if:

• you feel well enough to do some or all of the daily activities you did before your illness.

If you are receiving temporary free care while on the home ward, this will continue in the short term while you improve.

If a night sitter has been provided, this will only be up to seven nights.

We would hope that within approximately two weeks, the care is no longer needed. If you are still not able to manage, the Neighbourhood team will make a referral to Adult Social Services to take over. The care would then be means tested and you may need to make a financial contribution.

If palliative end of life care is needed following discharge, the Home Ward team will arrange this. Your care will then be provided by the Neighbourhood team with support from the local hospice.