Hertfordshire

Outline of Service

CLCH operates five integrated locality teams who support patients in their place of residence, providing holistic and evidence based interventions. 

The community nursing needs may include (not exhaustive); wound care, catheter care, care at end of life, administration of IV antibiotics or time dependent injectable medication i.e. insulin. 

The service includes domiciliary phlebotomy

Exclusion criteria: 

• Patients who are able to access clinics with support (i.e. family support)
• Nursing home residents

Operating hours:

8:00am to 8:00pm, 7 days a week including bank holidays.

Overnight nursing 8:00pm to 8:00am 

Referral route

GP’s can make referrals to the service via DXS.

Alternative services can obtain a copy of the referral form via CLCH Single Point of Access or via NHS.net.

CLCH staff – Community Adult Health Service Referral Letter on SystmOne. Completed forms to be emailed to the correct email address:

• clcht.dacorumspoc@nhs.net
• clcht.hertsmerespoc@nhs.net
• clcht.stalbansandharpendenspoc@nhs.net
• clcht.watfordspoc@nhs.net
• hertsplanned.carehometeam@nhs.net

CLCH Single Point of Access telephone: 03000 200 656, (option 2, option 1)

Patient outcomes

• Referral screening and clinical triage for eligibility/suitability
• Proportionate initial assessment of clinical needs and identification of treatment goals using person centred approach
• Treatment scheduled in advance of care being delivered and in line with clinical needs.
• Interventions delivered by skill mixed team with oversight from registered nurse or Allied Health Professional;
• Focus on self management / supporting patients to access clinic based services where needed.
• Upon discharge, the patients own GP will be informed of the treatment provided and any further recommendations.

Service response times:

Outline of Service

CLCH operates four integrated locality teams who support patients in their place of residence, providing holistic and evidence based interventions. 

Example referral reasons include (not exhaustive) reduced mobility, difficulty with activities of daily living, falls, post operative rehabilitation. 

Inclusion criteria: 

Housebound patients or delivery of therapy assessments and interventions which can only be delivered in a person’s home environment

Operating hours:

8:00am to 5:00pm, 6 days a week including bank holidays.

Referral route

GP’s can make referrals to the service via DXS.

Alternative services can obtain a copy of the referral form via CLCH Single Point of Access or via NHS.net.

CLCH staff – Community Adult Health Service Referral Letter on SystmOne.

Completed forms to be emailed to the correct email address:

• clcht.dacorumspoc@nhs.net
• clcht.hertsmerespoc@nhs.net
• clcht.stalbansandharpendenspoc@nhs.net
• clcht.watfordspoc@nhs.net

CLCH Single Point of Access telephone: 0300 020 0656 (option 2, option 1)

Patient outcomes

• Referral screening and clinical triage for eligibility/suitability
• Proportionate initial assessment of clinical needs and identification of treatment goals using person centred approach
• Treatment scheduled in advance of care being delivered and in line with clinical needs.
• Interventions delivered by skill mixed team with oversight from registered nurse or Allied Health Professional;
• Focus on self management / supporting patients to access clinic based services where needed.
• Upon discharge, the patients own GP will be informed of the treatment provided and any further recommendations.

Outline of Service

CLCH operates four geographical complex case management teams:

• Watford and Three Rivers
• St Albans and Harpenden
• Hertsmere
• Dacorum

Each locality has one complex case manager and one complex care case coordinator who provide a pathway focussed on the needs of the most complex presentations in the locality.

Operating hours:

Monday to Friday, 9:00am to 5:00pm

Referral route

GP’s can make referrals to the service via DXS.

Alternative services can obtain a copy of the referral form via CLCH Single Point of Access or via NHS.net.

CLCH staff – Complex Case Management including MDT and Frailty Clinic Referral Letter on SystmOne

Completed forms to be emailed to the correct email address:

• clcht.dacorumspoc@nhs.net
• clcht.hertsmerespoc@nhs.net
• clcht.stalbansandharpendenspoc@nhs.net
• clcht.watfordspoc@nhs.net
• hertsplanned.carehometeam@nhs.net

CLCH Single Point of Access telephone: 0300 020 0656 (option 2, option 1)

Patient outcomes

• Referral screening and clinical triage for eligibility/suitability
• Proportionate initial assessment of clinical needs and identification of treatment goals using person centred approach
• Three main offers:
• Complex Case Management 12 week pathway
• Frailty Clinic
• Locality Complex Case and Frailty Multidisciplinary Team Meeting Forum

Main outcomes:

• Care coordination / navigation
• Shared risk decisions across MDT
• Optimisation of long term conditions management and support of self management approaches
• Treatment escalation and/or anticipatory care planning.
• Upon discharge, the patients own GP will be informed of the treatment provided and any further recommendations.

​​​​​

Outline of Service

Dedicated outreach service delivered by a Lead Nurse from CLCH and support workers from Mind in mid Herts Charity. People living with a diagnosis of severe mental illness (i.e. Schizophrenia) are entitled to have a yearly physical health check. This service takes responsibility for engagement with individuals who GP’s have not been able to make contact with, with the aim of increasing future engagement with Primary Care.

Physical health checks will take place within the year of referral.

Operating hours:

Monday to Friday, 9am to 5pm

Referral route

Referral cohorts are to be emailed to:

clcht.smiphysicalhealth@nhs.net

CLCH Single Point of Access telephone: 0300 020 0656 (option 2, option 1)

Direct line: 07920 701094

Patient outcomes

Patients and/or carers can expect the following;

• Contact will be made in the person’s preferred method, if this is known, and the team will continue for as long as required to engage the person with the service.
• Assessment will be scheduled either at the person’s own home or in a clinic setting.
• The Physical Health Check follows the national guidance and as examples (not exhaustive) includes monitoring of weight, smoking status, blood sampling to check cholesterol.
• Onward referrals will be made as identified
• Findings of the Physical Health Check will be returned to Primary Care for coding on EMIS
• Quarterly meetings will be held with GP surgeries to discuss referral cohorts and outcomes. 

Outline of Service

The  Adult Speech and Language Therapy service provides assessment, treatment, support and advice to adults with acquired communication and/or swallowing disorders. We also see adults with developmental fluency difficulties.

This covers all aspects of communication, including speech, language and voice. The team works virtually, in community clinics, specialist care centres, nursing and residential homes and patients’ own homes. 

Operating hours:

8.30am to 4.30pm, Monday to Friday

Referral route

GP’s can make referrals to the service via DXS.

Alternative services can obtain a copy of the referral form via CLCH Single Point of Access or via NHS.net.

CLCH staff – Adult Speech and Language Therapy Referral Letter on SystmOne.

Completed forms to be emailed to the service email address:

clcht.westherts.slt@nhs.net

CLCH Single Point of Access telephone: 0300 020 0656 (option 2, option 3)

Patient outcomes

• Speech and Language therapists will provide a range of evidence based, goal specific, specialist interventions for adults with an acquired speech, language, communication difficulties and/or swallowing difficulties.
• Patient specific education and self-management programmes will be offered.
• SLT staff will work closely with families and carers to support the patient’s communication and swallowing needs. 
• Upon discharge, the patient's own GP will be informed of the treatment provided and any further recommendations.
• Service response times

Outline of Service

Patients will be referred to the Cardiac Rehabilitation Programme following a secondary care in-patient admission. Referrals are also accepted from the Community Heart Failure Service or the patient’s own GP, once a patient’s condition has been stable for three months.

The service offers phase 2 and phase 3 cardiac rehabilitation services, specialist wellbeing support, medication optimisation and dietary advice.

Inclusion conditions:

• Myocardial infarction
• Percutaneous Coronary Intervention (Stents)
• Coronary Artery Bypass Surgery
• Heart valve replacement or repair
• Stability of Heart Failure

Exclusion:

• Acute or unstable cardiac conditions

Operating hours:

8.30am to 4.30pm,  Monday to Friday

Referral route

GPs can make referrals to the service via DXS.

Alternative services can obtain a copy of the referral form via email:
clcht.westherts.communitycardiology@nhs.net

or CLCH Single Point of Access telephone: 0300 020 0656 (option 2, option 5)

Patient outcomes

• Referral screening and clinical triage for eligibility/suitability
• Phase 2: Telephone contact to patients to discuss cardiac health, guidance on activity and lifestyle changes and to introduce the Cardiac Rehabilitation programme
• Phase 3: Patients will receive an initial assessment, group programme and post programme assessment.
• The cardiac rehabilitation exercise programme runs for 8 weeks and will be undertaken in a group either face-to-face or virtually. A one-to-one individualised home programme will be offered if clinically indicated. 
• The service also offer a 6-week rolling virtual education programme designed to guide patients in the self-management of their cardiac health. There is also a separate virtual Heart Failure education programme that also runs quarterly. 
• Upon discharge, the patients own GP will be informed of the treatment provided and any further recommendations.

Outline of Service

The Heart Failure specialist team provides specialist assessments, and management as well as education in self-management strategies to support patients and their family & carers. 

The service will see patients with a heart failure diagnosis (confirmed diagnosis on ECHO/MRI) 

• HFrEF – Ejection Fraction ≤40%
• HFpEF –Ejection Fraction ≥40% with evidence of diastolic dysfunction or RV dysfunction or severe valvular disease for medical management

Operating hours:

9:00am to 5:00pm,  Monday to Friday

Referral route

GPs can make referrals to the service via DXS.

Alternative services can obtain a copy of the referral form via CLCH Single Point of Access or via NHS.net.

CLCH staff – West Herts Heart Failure Referral Letter on SystmOne

Completed forms to be emailed to the service email address:

 clcht.westherts.communitycardiology@nhs.net

Telephone: 03000 200 656 (option 2, option 5)

Patient outcomes

• Referral screening and clinical triage for eligibility/suitability
• The Heart Failure specialist service will titrate medication to stabilise the patient’s heart failure. 
• The Heart Failure specialist nurses will instigate end-of-life planning and provide advice and support with advanced care planning in conjunction with palliative care teams or GP. 
• Upon discharge, the patient's own GP will be informed of the treatment provided and any further recommendations for ongoing management.
• The Heart Failure specialist nurse also work with WHHT to provide a Virtual Hospital service to try to prevent admission/promote early discharge. This may include intravenous diuretics in conjunction with the rapid response team (see Heart Failure Virtual Hospital service slide).

Outline of Service

The Adult Bladder and Bowel Care Service is a nurse-led service that provides specialist assessments, diagnosis and treatments to adults within the community.

The service provides support and advice for:

• Bladder Dysfunction
• Bowel Dysfunction
• Incontinence products, including containment products and sheaths
• Intermittent self-catheterisation
• Catheter advice/support for healthcare professionals

Operating hours:

8:00am to 4:00pm, Monday to Friday

Referral route

GPs can make referrals to the service via DXS.

Alternative services can obtain a copy of the referral form via CLCH Single Point of Access or via NHS.net.

Telephone: 03000 200 656 (option 2, option 6)

CLCH staff – West Herts Bladder and bowel Referral Letter on SystmOne.

Completed forms to the service email address:

clcht.westherts.bladderandbowel@nhs.net

Patient outcomes

Patients and/or carers can expect the following;

• Patients will be contacted by the service and booked in for either a telephone assessment or face to face clinic.
• Following assessment, patients will be provided with an explanation of the outcome of the assessment and of the proposed treatment/management options available
• Patient’s preferences and choices will  be taken into consideration throughout
• Contact details for follow up advice/support from the appropriate service will be given as required.
• Details of National Support Groups and referrals to Herts Help and/or Carers in Hertfordshire for access to local support groups where the user/carer would find this helpful
• Upon discharge, the patients own GP will be informed of the treatment provided and any further recommendations.

Outline of Service

A multidisciplinary rehabilitation team who provide a holistic, patient centred approach to support people experiencing Long Covid. 

Inclusion criteria: 

• Aged 18+
• Indication of Long Covid, through exclusion of other health conditions via: blood test, ECG and chest Xray. 

Operating hours:

9.00am to 5.00pm, Monday to Friday

Referral route

GP referrals only - via DXS.

clcht.westhertslongcovidadmin@nhs.net

Patient outcomes

Patients and/or carers can expect the following;

The team provide a mixture of face to face and virtual interventions which include: 

A holistic assessment 

• Fatigue management 
• Vocational rehabilitation & AHP reporting 
• Management of brain fog 
• Breathlessness advice and rehabilitation 
• Exercise prescription rehabilitation programme
• Cognitive Neuro-Rehab Group Therapy
• Mindfulness and Relaxation Group
• Onward referral for further investigation and specialist service intervention

Outline of service

The integrated respiratory service is delivered through a combination of nurse/physio clinics, consultant clinics and home visits.  Patients can access;

• Community Asthma, Bronchiectasis and COPD Service
• Hospital at Home Service
• Obstructive Sleep Apnoea Service (OSAS)
• Pulmonary Rehabilitation 
• Home Oxygen Service Assessment & Review (HOS-AR)
• Community Tuberculosis (TB)

Operating hours:

9.00am to 5.00pm , Monday to Friday

Hospital at Home 9.00am to 5.00pm, 7 days a week

Referral route

GPs can make referrals to the service:

• Elective care using DXS forms
• Hospital at Home - contact the Advice Line 9-5pm 7 days a week on m: 07944 860925. 
• Watford Hospital Ward Discharges / Virtual Hospital Discharge referrals +

CLCH staff – send an email with attached clinical letter to the service email address:

clcht.respiratoryrms@nhs.net

External services who do not use DXS e.g. Other Acute Hospitals, or Hospital Depts, to email queries or referrals to the generic email: westherts.resp@nhs.net 

Telephone: 03000 200 656 (option 2, option 4)

Patient outcomes

Patient outcomes vary depending on service and interventions offered and carried out. 

All patients can expect:

• Advice and guidance from a respiratory specialist
• A comprehensive assessment and treatment plan.
• Regular monitoring and follow up assessment as needed. 

Outline of Service

Many services provide palliative care to their patients and the Specialist Palliative care Service is available to support patients and staff when more complex interventions are required

The Specialist Palliative Care team is made up of Highly trained professionals including Clinical Nurse Specialists, palliative Consultants and administrative staff who support patients and carers with complex specialist palliative care needs.

Operating hours

9.00am to 5.00pm , 7 days a week

Referral route

GPs can make referrals to the service via DXS.

Direct Number Mon to Fri is 0208 102 6236

Weekends telephone: 03000 200 656 Option 1, option 0

24 Hour advice line for patients, carers and professionals:

01923 335356

Referrals for community, outpatient and Inpatient admission can be made on a referral form and sent to:

Westherts.pcrc@nhs.net 

Patient outcomes

Patients and/or carers can expect the following:

• We offer Specialist Palliative Care to people who have a life- limiting illness that requires specialist intervention and expertise.
• The aim of Palliative care is not to cure but to relieve suffering related to physical, psychological, spiritual and emotional issues, improving the quality of life of the person who is ill and supporting the people caring for them.
• We provide expertise in pain and symptom management and psychological needs 
• We will support and help patients and their families plan for the future, by assisting them to think about and record what matters to them in their future care.
• We work in collaboration with other services

Outline of Service

The Community Leg Ulcer Service (delivered by Herts One GP federation) provides management of patients who have venous leg ulceration which is suitable for high compression therapy or who have leg ulcers of mixed aetiology (arterial and venous) which are suitable for modified compression therapy.

Exclusion criteria:

• Non- ambulatory patients or arterial leg ulcers (refer to CLCH NHS Trust Planned care or TVNs)
• Diabetic foot ulcers
• Lymphoedema (refer to CLCH NHS Trust Lymphoedema service)
• The service run clinics in all 5 localities in West Hertfordshire.

Operating hours:

9.00am to 5.00pm, 7 days a week

Referral route

GPs can make referrals to the service via DXS.

Alternative services can obtain a copy of the referral form via CLCH Single Point of Access or via NHS.net.

Telephone: 03000 200 656 (option 2, option 7)

CLCH staff –West Herts TVN Service Referral Letter on SystmOne.

Completed forms to be emailed to the service email address:

clcht.westherts.tvn@nhs.net

Patient outcomes

Patients and/or carers can expect the following;

The service aims to appropriately manage the care of patients with new and existing leg ulceration who would benefit from compression therapy.

The objectives of the service are to:

• To provide nursing assessment and diagnosis of leg ulcer aetiology for ambulant patients
• To provide on-going treatment and evaluation up to healing
• To provide support for aftercare and prevention of re-occurrence of ulceration
• To provide educational advice to support patients in the management of their skin

​

Outline of Service

Tissue Viability provides advice, care planning and treatment of non-healing and complex wounds. We provide our service independently but also support planned care, GPs, practice nurses and care or nursing homes. Referrals for all non-healing complex wounds excepted accept for the following:

• Ambulatory patients with venous or mixed aetiology leg ulcers (referrals should be made to the Herts One leg ulcer service)
• Ambulatory patients that have Diabetic Foot Ulcers (referrals should be made to the Herts Integrated Diabetes Service Podiatry Service)
• Cellulitis without active ulceration
• For routine lymphoedema care.
• Direct referrals from Residential Care Homes (referrals should be made via planned care of GP)

The team visit patients in their place of residence.

Operating hours:

9.00am to 5.00pm, Monday to Friday

Referral route

GPs can make referrals to the service via DXS.

Alternative services can obtain a copy of the referral form via CLCH Single Point of Access or via NHS.net.

Telephone: 03000 200 656 (option 2, option 7)

CLCH staff –West Herts TVN Service Referral Letter on SystmOne.

Completed forms to be emailed to the service email address:

clcht.westherts.tvn@nhs.net

Patient Outcomes

• Referral screening and clinical triage for eligibility/suitability
• Tissue Viability Nurses will assess the patient and develop their personalised treatment and management plan, with the patient and carers, which will be shared with the referrer and the clinician responsible for the patient’s care.
• Patients will normally be discharged once their personalised treatment and management plan has been developed, unless the Tissue Viability Nurse assesses the patient requires a second review, which will be scheduled during the assessment.

Outline of Service

The service is accessible to non-ambulatory and ambulatory patients with both genetic or acquired lymphoedema and lipoedema. The team aims to

ensure positive and sustainable patient outcomes in relation to clinical needs, quality of life and wellbeing.

Exclusion criteria:

• End stage cardiac condition
• End stage renal failure
• Patients with a BMI of 40+ not under active weight management

Clinics:

1. The Avenue - Watford
2. Marlowes – Hemel Hempstead
3. Harpenden Memorial Hospital
4. Skidmore Way - Rickmansworth
5. St Albans Civic Centre

Operating hours:

9.00am to 5.00pm, Monday to Friday

Referral route

GPs can make referrals to the service via DXS.

Alternative services can obtain a copy of the referral form via CLCH Single Point of Access or via NHS.net.

Telephone: 03000 200 656 (option 2, option 7)

CLCH staff – West Herts Lymphoedema service Referral Letter on SystmOne.

Completed forms to be emailed to the service email address.

clcht.westherts.lymphoedema@nhs.net

Patient outcomes

Referrals are triaged to ensure their suitability of the service. Patients will then receive a full clinical assessment of the lymphedema either in clinic, at home or visit or virtually.

All patients with lymphedema will receive a coordinated treatment plan, at a level of intervention appropriate to their needs. This will include:

• Comprehensive assessment
• Treatment plan in line with the Lymphoedema Framework
• Active treatment
• Intensive treatment , followed by maintenance therapy for complex presentations
• Simple interventions for mild to moderate lymphedema
• Regular follow-up at intervals dependent on patient needs
• Supported self-management programmes and discharge plan.

Outline of Service

Our podiatry team provides assessment, diagnosis and treatment of disease and conditions affecting the foot and lower limb in a clinic setting.

Treatments are focused on relieving symptoms, improving function, disease prevention, and maintaining independence and well-being.

We see people who are having problems with their feet and we provide assessment, diagnosis and treatment of disease and conditions affecting the foot and lower limb.

Exclusion:

• Diabetes
• Patients who are unable to attend clinics (no domiciliary service)

Operating hours:

9.00am to 5.00pm , Monday to Friday

Referral route

GPs can make referrals to the service via DXS.

Patients are able to self refer here

Alternative services can obtain a copy of the referral form via CLCH Single Point of Access or via NHS.net.

Telephone: 03000 200 656 (Option 2, option 2)

CLCH staff – West Herts Podiatry service Referral Letter on SystmOne.

Completed forms to be emailed to the service email address:

clcht.westherts.podiatry@nhs.net   

Patient outcomes

Patients and/or carers can expect the following;

• Screening and treatment of at-risk patients
• Chronic and acute ulcer management (non-Diabetic patients only)
• Orthotic and insole prescription and manufacture for feet
• Nail surgery, including diabetic patients
• Removal of corns, and other soft tissue lesions for High-risk patients
• Health promotion, education and advice
• Maintenance care for chronic and irreversible foot problems for high-risk patients.

Outline of Service

The service provides:

• Information, testing and treatment for sexually transmitted infections (STI’s) such as Chlamydia, Gonorrhoea, Syphilis, HIV, Thrichomoniasis, Herpes, Warts and Hepatitis.
• Rapid HIV testing
• Advice and Information
• All methods of contraception
• Emergency contraception
• Pregnancy testing
• Free Condoms
• Post Exposure Prophylaxis (PEP) and Pre Exposure Prophylaxis (PrEP)

Sexual Health Hertfordshire is provided from the following sites::

1. Hatfield Centre
2. Watford Sexual Health Centre
3. Southgate Centre, Stevenage
4. Elstree Way Clinic
5. Cheshunt Clinic

Online STI screening and contraception available via the Hertfordshire sexual health website

Operating hours:

9.00am to 5.00pm, Monday to Friday.
2 x extended clinics (until 8:00pm) per clinic site per week.

Referral route

Telephone: 0300 008 5522

Patients are able to self refer via the website: Sexual Health Hertfordshire

GPs can make referrals to the service via DXS/ SystmOne.

Professional referral forms are also available on the website:

Sexual Health Hertfordshire and are sent to the patients preferred clinic:

• Watford: clcht.shwreception@nhs.net 
• Hatfield: clcht.hat-reception@nhs.net
• Stevenage: clcht.ste-reception@nhs.net

Patient outcomes

Patients and/or carers can expect the following:

• Walk in clinics are available at all sites and patients are able to book appointments for some services through the website
• The single point of access for the service manage professional referrals and positive results from SH:24.

Clinics provided include:

• Nurse led routine
• Symptomatic
• Asymptomatic
• Complex GUM
• Complex LARC
• HIV
• Clinic U (LGBTQ+)
• Electrocautery

All patients receive an assessment of their sexual, social and medical history and baseline screening for HIV, Syphilis, Chlamydia and Gonorrhea.

Patients will be provided with the appropriate intervention and discharged from the service.

Outline of Service

Patient’s receive rehabilitation services in a supportive environment, delivered by a skilled and dedicated team of rehabilitation specialists.

Personalised rehabilitation programs are designed collaboratively, for individual needs and goals with a holistic approach to healing.

CLCH provide 4 inpatient rehabilitation wards in which the majority of patients will have their own single occupancy comfortable room.

Multiprofessional teams include: Nurses, Therapists, Support workers, Doctors, Speech and Language therapists and others.

Referral route

Referrals are to be sent to the Single Point of Contact team email:

westherts.dtaspoc@nhs.net

Telephone: 07813 400514

Ward direct contact numbers and locations:

• Oakmere Ward 

Potters Bar Community Hospital EN6 2RY

Tel: 01707 653286
 

• St Peters Ward

Hemel Hempstead General Hospital, HP2 4AD

Tel: 01442 287602
 

• Midway Ward

Langley House, Watford, WD25 9FG

Tel:  01923 681167

• Holywell ward (Neurological rehabilitation) 

Langley House, Watford, WD25 9FG

Tel:  01923 686820

Patient outcomes

Patients and/or carers can expect the following:

Referrals will be triaged by the Single Point of Contact team based at Watford General Hospital for suitability for the service. Additional information may be requested from referrers if needed. 

Hospital transport can support patients on to the ward.

The team will complete an initial assessment and develop a personalised rehabilitation programme which may focus on: Improved Mobility, Pain Management, Increased Independence,  Enhanced Strength and Endurance, Optimised Balance and Coordination, Functional Skills, Successful Adaptive Strategies, Patient Education with a view to discharge to an appropriate location.

Referrals for ongoing community support will be made for ongoing functional and mobility needs.

Outline of Service

The Early Intervention Vehicle (EIV) is a jointly delivered service by CLCH and Hertfordshire County Council and provides an urgent response to those in crisis, which typically includes people who have fallen.

The EIV team comprises of Nurses/ Paramedics, Occupational Therapists, Physiotherapists and social workers and the objective is a joint assessment at the initial point of contact to provide safe admission avoidance solutions, and / or referral to appropriate care pathways.

Inclusion: 

• Aged 65+
• Exclusion:
• Life threatening condition requiring hospital level care

Operating hours:

7 days a week, 8:00am to 8:00pm

Referral route

Verbal referral to the Urgent Community Response Care Coordination Centre:

Telephone: 03000 200 656 (option 2, option 8)

Patient outcomes

• Patients and/or carers can expect the following;
• Referrals are triaged on receipt to ensure they are appropriate for the service. 
• Patients will receive a holistic assessment within 2 hours
• Patient's may receive treatment as indicated such as wound care or be provided with equipment to increase safety and aid function 
• If required, implementation of a new or increased social care package will be arranged
• Typically patients receive an assessment only, with onward referral into appropriate services (which may include Rapid Response or planned care services)
• A discharge letter will be sent to the patient and their registered GP.

Outline of Service

Physiotherapy/ Occupational Therapy  assessment in a medically optimised patient’s usual place of residence, within 24 hours of discharge from an inpatient hospital stay.
This service supports Discharge Pathway 1 (therapy at home) and Discharge Pathway 3 (short term care home placement)

Exclusion: 

• Where a patient’s primary reason for admission is mental health related (patients will be accepted where a joint care plan can be implemented with mental health services)
• Patients who are imminently End of Life 
• Patient who are completely Independent or at baseline and unlikely to change in functional ability once at home. 

Operating hours:

Pathway 1: 8:00am to 6:00pm, seven days a week 

Pathway 3: 8:30am to4:30pm, Monday to Friday 

Referral route

Referrals are to be sent to the Single Point of Contact team email:

westherts.dtaspoc@nhs.net

To speak to the team, please call the:

Urgent Community Response Care Coordination Centre

Telephone: 03000 200 656  (option 2, option 8

Patient outcomes

Patients and/or carers can expect the following:

• Referrals are triaged on receipt to ensure they are appropriate for the service 
• An initial assessment includes a functional assessment, safety based environment assessment and determines rehabilitation goals 
• The team will liaise with other providers involved in patients care (i.e. specialist care at home) to promote rehabilitation 
• If further input is required following intervention, onward referrals will be made in to planned care services for longer term rehabilitation
• Upon discharge, the patient's own GP will be informed of the treatment provided and any further recommendations.

Outline of Service

Urgent Community Response Service for housebound or temporarily housebound adults at risk of imminent hospital admission. 

Any appropriate patients will be stepped up into virtual hospital pathways for medical oversight and monitorring.

Operating hours:

7 day service, 8:00am to 10:00pm (Referrals accepted until 8pm)

Referral route

Urgent Community Response Care Coordination Centre:

Telephone: 03000 200 656 (option 2, option 8)

Patients referred must have been clinically assessed virtually or face to face within the previous 24 hours, have a working diagnosis and be at imminent risk of hospital admission

Patient outcomes

• Patients are assessed within 2 hours of receipt of referral
• A comprehensive assessment is completed with appropriate diagnostics 
• A personalised care and support plan is developed in conjunction with the patient  and their family/carers and delivered for up to 5 days 
• The team consists of non-medical prescribers and GP's seven days a week
• Patients will be referred on to appropriate services during intervention and a discharge letter sent to their registered GP on discharge. 

Outline of Service

The Community Neurological Rehab Service provides Specialist therapy and nursing interventions to patients with Long term, Neurological conditions living in the community. According to the intensity of  needs the service will offer complex care, need led intervention and self-management interventions.

Criteria:

• Age 16 years or over (unless subject to an EHP where they will remain the responsibility of paediatric services until the age of 25 years, or in full time education until age 18). Those in a transitional phase between child and adult services may be jointly screened to assess suitability.  
• Have a diagnosed neurological condition confirmed by a neurologist, which is the primary reason for referral. In cases of MND, PSP & other rapidly progressing conditions, the patient may be accepted before a formal diagnosis, where the patient is under the care of or has been referred to a neurologist.
• Have needs which can only be met by the neurological service working either as a standalone service or in partnership with others, e.g. rapid response

Operating hours:

8:30am to 4:30pm, Monday to Friday

Referral route

GPs can refer to the service via DXS.

Other professionals can request a referral form via NHS.net

Telephone: 03000 200 656 (option 2, option 9 )

clcht.westherts.neuro@nhs.net 

Patient outcomes

• Clinical triage will be undertaken within 48 hours of receipt of the referral by the service.
• Urgent patients (those with rare and rapidly progressing conditions e.g. MND, advanced stage of disease with high risk of in-patient admission if not seen) will have first clinical assessment within 2 working days of triage.  
• Routine-urgency patients (with need for therapy or nursing intervention regarding on-going conditions which are stable, this may include rehabilitation, and adjustment relating to physical, cognitive or mood conditions) will be seen within 6 weeks of triage.
• The Community neuro team will assess the patient and develop their personalised treatment and management plan, which will be shared with the referrer and the consultant responsible for the patient’s care, where appropriate.
• The service will  will coordinate and case manage patients to ensure they are linked into the most appropriate services. 
• The team will identify and source any required specialist equipment.

Outline of Service

ICSS coordinates the transfer of care of stroke survivors from hospital through specialist MDT to community provision, this includes early specialist community stroke rehab and disability management. This also includes patients who have had a sudden or new onset of a neurological symptom which has involved a hospital stay. 

The service offers a range of levels of intensity and type of intervention depending on stage of treatment and patient need. It consists of three pathways, Early supported discharge (ESD), Neuro enhanced transition team (NETT) and Community stroke pathway. 

Inclusion Criteria:

• Has suffered a stroke 
• Predicted life expectancy is more than 48 hours

Operating hours:

Monday to Sunday, 9:00am to 5:00pm, 7 days a week

Referral route

Referrals are accepted from Acute and Hyperacute Stroke units via CLCH Single Point of Access

Telephone: 03000 200 656 (option 2, option 9 )

clcht.westherts.neuro@nhs.net

Patient outcomes

• The service provides intensive rehabilitation at home for up to 6 weeks, thereby reducing the risk of re-admission increasing independence and quality of life. 
• ESD Intervention will commence within 24 hours of discharge from hospital where an initial assessment will take place. Initial assessments are available 6 days Monday to Saturday at a stroke patients’ place of residence for a period of up to 6 weeks.
• NETT Intervention will commence within 72 hours of discharge from hospital. Initial assessments will be available 5 days Monday to Friday at the patients’ place of residence for a period of up to 6 weeks. 
• Stroke patients will be offered intensive therapy sessions, (target of 45 mins per discipline where appropriate, 5 days a week) to an intensity equivalent to in hospital rehabilitation, but reflective of individual patient needs and goals. 
• This service will provide carers/family with appropriate education and training related to stroke/neuro rehab and prevention. 

Outline of Service

Delivered in partnership between CLCH and West Hertfordshire Teaching Hospital Trust (WHTHT).

The service supports acutely unwell frail patients to receive hospital level care at home, using a blend of face to face and remote monitorring for patients who would otherwise be admitted to hospital.

Criteria: aged 65+ with a clinical frailty score above 4

Operating hours:

7 days a week, 8:00am to 8:00pm

Referral route

Verbal referral in to the Urgent Community Response Care Coordination Centre:

Telephone: 03000 200 656 (option 2, option 8)

Patient outcomes

• Admission avoidance assessment by the Urgent community Response service within 2 hours– suitable patients will be internally stepped in to the Frailty Hospital at Home service
• Patients will receive an assessment within 24hours of receipt of referral from a highly skilled Nurse/Allied Health Professional
• A personalised care and support plan will be developed with the patient for a period of up to 14 days
• Remote monitorring, where appropriate, will be issued and feed in to the Virtual Hospital Hub at WHTHT
• A treatment escalation plan will be agreed with the patient and their family/carer and clearly documented
• Advance Care Planning will be instigated using the RESPECT form
• A Daily MDT will take place with a Consultant Geriatrician to discuss treatment plans, any requirement for escalation and access to diagnostics
• Patients will be referred on to appropriate services during intervention and a discharge letter sent to their registered GP on discharge.

Outline of Service

Delivered in partnership between CLCH and West Hertfordshire Teaching Hospital Trust (WHTHT)

Referrals are accepted from WHTHT and from Primary Care.

Criteria:

• Patient with confirmed Heart Failure (via Echo) with new or deteriorating heart failure symptoms
• Shortness of Breath
• Lethargy
• Oedema

Operating hours:

Virtual Hospital Hub: 8:00am to 6:00pm, 7 days a week service

Referral route

Telephone: 03000 200 656 (option 2, option 5)

West Herts Community Heart Failure Nurses Referral Form [available on DXS] with ECHO emailed to: clcht.westherts.communitycardiology@nhs.net

Please state referral reason is for Virtual Hospital 

Patient outcomes

For community patients requiring immediate assessment for virtual hospital, please contact Rapid Response via the Urgent community Response Care Coordination Centre

• Remote monitoring devices which record observations are provided to the patient which they upload to a web-based platform via an app
• Watford General Virtual Hospital Hub staff monitor the  results and telephone the patient up to 4 x a day. Any concerns highlighted are escalated to a Consultant at WHTHT
• Patient is discussed at a daily Virtual Hospital Consultant led ward round and in the Multidisciplinary team meeting once a week
• Where required, patients are visited by the community Heart Failure Team
• Patients will remain on the service for up to 14 days 

Outline of Service

Delivered in partnership between CLCH and West Hertfordshire Teaching Hospital Trust (WHTHT) including input from Primary Care and the Voluntary Sector. Service length of stay aim is up to 7 days. 

Criteria:

• Acute exacerbation of COPD/Asthma/Bronchiectasis
• GPs who require an assessment at home to prevent admission for an acute exacerbation of COPD/Asthma/Bronchiectasis.

Operating hours:

Virtual Hospital Hub: 8:00am to 6:00pm, 7 days a week service

Referral route

Telephone Respiratory Advice Line:

07944 960 825

7 days a week, 9:00am to 5:00pm

Patient outcomes

• Telephone screening will be undertaken via the advice line holder to identify if patient is suitable for virtual hospital
• Patients will be seen face to face same day if referred before 3pm or next day
• Patients will be started on exacerbation medication (+/- antibiotics, +/- oral steroids)
• Patient will be required to attend for a chest X-Ray
• Blood tests will be undertaken within the home or requested at a blood clinic
• Remote monitoring devices which record observations are provided to the patient which they upload to a web-based platform via an app
• Patients will receive regular contact from the Virtual Hospital Hub team.
• Patients will be discussed at MDTs
• Patients will be discharged back to their registered GP once improved.

Outline of Service

Delivered in partnership between CLCH and West Hertfordshire Teaching Hospital Trust (WHTHT) including input from Primary Care and the Voluntary Sector.

Criteria:

• Registered with a South and West Hertfordshire GP and Post Code.
• Clinical presentation: Community Acquired Pneumonia CRB65 1-2 or suspected COVID/Flu. Oxygen Sats >94% air or 88-92% COPD

Operating hours:

Virtual Hospital Hub: 8:00am to 6:00pm, 7 days a week service

Referral route

Referrals from Primary Care, Ambulance Service and Community Health Services is via:

Urgent Community Response Care Coordination Centre

Telephone: 03000 200 656 (option 2, option 8)

Patient Outcomes

• 2 hour assessment from a Rapid Response Clinician where the individual is at risk of hospital admission
• Remote monitorring devices are issued to patients on the pathway
• WHTHT virtual hospital hub staff contact the patient a minimum of once a day to discuss their clinical presentation and monitor the remote monitorring diagnostic results and any alerts received
• If a patient is considered to be deteriorating they will receive a face to face visit from the Rapid Response Team
• The virtual hospital hub team can escalate to the WHTHT Respiratory Consultants for advice
• Patients will be discharged from the service at day 7
• Follow up chest Xray and any other required tests at 6 x weeks post discharge with a review by the Virtual Hospital Consultant

Download CLCH's pathway guide for GPs