Epsom Health and Care '@home'

The Epsom Health and Care '@home' service is for people aged over 65 who are living in Epsom and the surrounding areas (including Leatherhead). It particularly supports those who have two or more long term conditions to live as independently as they can and to prevent them getting acutely unwell by coordinating all of the health and social care services they need. As extra support and care is provided within a person’s home, it means that people should only have to stay overnight in hospital when they are very unwell.

The service is provided by one team of people from across health and social care services, including community doctors, nurses, physiotherapists, occupational therapists, community matrons and re-ablement assistants from social care. Their role is to support people to live as independently as they can - so they stay well enough not to have to spend time in hospital. The team works from several locations in the Epsom area, including at the New Epsom and Ewell Community Hospital (NEECH), on the Epsom General Hospital site, and at Epsom Town Hall.

The team works closely with mental health, voluntary and community organisations, carer and patient representatives, district and borough councils so are able to access many other community services if required.

The service, which launched in October 2016, is provided through a partnership between Surrey County Council (who provide social care), ourselves - CSH Surrey (who provide NHS community health care in people's homes), Epsom and St Helier (who provide hospital-based, NHS services) and all of the 20 local GP practices. 

“I have many chronic conditions and the @home team has made a huge difference to me. I have had a lifetime of hospitals, so to be able to be cared for at home, and if I do have to spend time in hospital, to be able to come home sooner knowing all of the support I need is organised, is just fantastic – not just for me, but for my family too.”

Patient

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The @home service is provided in the best place for the person, which could be in their own home, or, if the team feels someone needs more in-depth assessments or diagnostic tests to better understand their health and care needs, they will ask them to visit the @home community doctors, nurses, therapists and social care team who are based at Epsom Hospital.

This team will thoroughly review the person’s situation and needs in the @home Community Assessment and Diagnostic Unit (CADU) and then arrange the required services. For example, for equipment to be delivered at home or for visits from doctors, nurses, physiotherapists, occupational therapists, community matrons or social care re-ablement assistants. The review could take a few hours, so people are given drinks and meals if necessary while they wait for the assessments, tests and results. Friends or family members are welcome to attend as well, and the CADU team can arrange transport if required.

The @home team will arrange additional short-term support at home for people who run the risk of becoming acutely unwell or who need extra support after being discharged from hospital. If someone’s care needs to be coordinated for longer, they will be supported by the specialist @home community matrons and dedicated care coordinators (who arrange all of the care someone needs at home).

The @home team will liaise with the individual, their family and carer(s), and communicate with each other to organise the care and services the person needs. This may include, for example, organising assessments or diagnostic tests, equipment to be delivered and set up at home, arranging outpatient appointments or transport, or arranging visits from community matrons and therapists.