Welcome to the page for the Home First service.
Skip straight to advice on how to refer to Home First.
Home First is an umbrella term for a range of services to patients to deliver a discharge to assess approach (D2RA) from hospital with ongoing care and assessment post discharge in a community setting.
Home First is a regional, multidisciplinary and integrated service which includes health, local authorities and third sector services.
Home First D2RA services offer rehabilitation at home or in a bedded reablement facility, therapy-only support, medication management, nursing and social worker support, wellbeing services via the third sector or complex needs assessments, which include ongoing assessment in a care home.
The aim is always to deliver a ‘home first ethos’ for our patients and to advocate ‘what matters to them’ with the teams working collaboratively with all our partners, patients and their families.
For patients with reablement needs, assessments are strength based with the goal to optimise, recover and rehab outside of an acute hospital environment, at home or where this is not possible in a designated reablement bed.
For those patients with complex needs the aim is to reduce assessment processes in hospital and transfer into a care home for a period of optimisation and assessment to determine longer term needs.
To support accessibility to services, Home First services provide a hospital-based team which includes therapists, social workers and community DLNs who are on site Monday to Friday to advocate D2RA, proportionately assess patients, expedite referrals, and advise hospital staff with any queries.
Home First team leads also attend the weekly clinically optimised (COP) meetings and patient escalation group.
Home First services have community discharge liaison nurses on site Monday to Saturday and provide a trusted assessor role to assess and transfer patients to Bonymaen House, Gorseinon Hospital and a large number of care homes for D2RA pathway three and step-up, step-down beds.
To refer to any of the Home First pathways, a referral process via Signal is required.
The referrer will need to complete all fields on the form and select a pathway for discharge to ensure the referral is processed and accepted in a timely way.
Referrals are discussed by the Home First community teams on the day they are received and the team will update Signal on the outcome or contact the referrer if more information is required.
Once the referral is accepted and processed, Signal will be updated on capacity to support the patient's discharge or next steps in their pathway.
(NB: A quality referral made at the right time with all fields completed and evidence of engagement with the patient will prevent unnecessary delays)
Contacts
Home First in-reach staff members can be contacted via coordinator onsite Cisco: 32321
Home First community in-reach teams can be emailed via
Rydym yn croesawu gohebiaeth a galwadau ffôn yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi. Mae’r dudalen hon ar gael yn Gymraeg drwy bwyso’r botwm ar y dde ar frig y dudalen.
We welcome correspondence and telephone calls in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. This page is available in Welsh by clicking ‘Cymraeg’ at the top right of this page.