Introduction to the service offer
NHSE guidance requires all Integrated Care Systems to have services that can deliver a Two-Hour Urgent Community Response (UCR) to patients who are acutely unwell at home and would otherwise be at risk of admission to hospital if they were not seen within two hours. Sheffield already has the Active Recovery service supporting both admissions avoidance and hospital discharges and the service is now working to offer a two-hour urgent community response when required.
Our Front Door Response Team (FDRT) based at the hospital are integral to the UCR offer and where appropriate will direct patients conveyed to the Emergency Department into this pathway.
Currently referrals can be made to the service by GPs, their Primary Care Colleagues and Community Teams, District Nurses, Therapists, Paramedics and ECPs by calling the STH Single Point of Access (SPA) (Health Care Professional) Line: 0114 2266 566 or 0114 271 3766 and selecting option 2.
The service is available from: 08:00 – 20:00 hours 7 days a week including bank holidays.
The criteria for patients are:
- Over 18 years of age.
- Registered with a Sheffield GP.
- The person is experiencing a crisis which can be defined as a sudden deterioration in their health and wellbeing.
- The crisis may have been caused by a stressor event which has led to an exacerbation of an existing condition or the onset of a new condition; or
- significant deterioration in clinical state or baseline functioning.
- This health or social care need requires urgent treatment or support within two hours and can be safely delivered in the home setting.
Following a referral for an Urgent Community Response an Active Recovery Generic Assessor (GA) i.e., a nurse or therapist will visit the patient in their home: –
- A holistic assessment is completed to identify and implement the health and social are required to keep the patient safe. Advanced Clinical Practitioners (ACP) are also able to visit to provide diagnostic and treatment plans alongside the Generic Assessors.
- Active Recovery can provide up to four single or double handed care and re-ablement visits daily (this does not include overnight provision).
- If social care is the only need identified a transfer to local authority enablement services will be arranged within 48 hours.
- The patient will be discharged from Active Recovery if/when a care plan is no longer required or if they are admitted to hospital. Depending upon the needs of the patient, they may be referred to the Local Authority Short Term Intervention Team (STIT) or Enablement Service, or to Independent Sector home care provision. The Active Recovery Assessment Team may refer on to other services at discharge if required e.g., Continence service, Community Nursing and Therapy.
The Active Recovery Assessment Team will assess for clinical, therapeutic and equipment needs as well as care and reablement needs. MDT access to mental health, dietetics and pharmacy is also available within the service.
You can access a comprehensive PDF copy of the Service offer below: