The Hub teams provide proactive care for medically stable patients. They focus on prevention, encouraging self-care, identifying risk factors and managing these early. The Hub services are particularly suitable for people who may benefit from support from both health and care services.
A reactive service to support people to stay at home through exacerbations and crises if this is safe and appropriate is provided through The Bedser Hub. This service will be extended to the other Hubs during 2018.
The Hub services aim to identify people with frailty or at risk of frailty at an early stage. Patients receive a multi-disciplinary proactive assessment to identify their needs and are provided with advice and treatment. They are also signposted to suitable services and have support put in place to help avoid a health or social care crisis.
The Hubs are not an alternative to GP or local community services, but work in partnership with these other services to provide a coordinating point for people with frailty. People remain on the Hub caseloads for life and people on the caseloads can access the service, and health and care professionals can refer them for a review, without the need for re-referral. Each person is allocated to a Hub coordinator, who will ring people on the caseload on a regular basis depending on need.
The patient's care record is shared with health, mental health and social care professionals involved in their care (following patient consent) and the team is notified when people on the caseload attend the Ashford & St Peter's Hospital A&E department or call the ambulance service. This helps the Hub teams identify when people may be going into crisis so they can offer support if necessary.
Specialist clinics are held in the Hubs for people on the Hub caseload.
People are encouraged to come to the Hubs for appointments if possible and free community transport is provided if needed. The community transport buses are specially adapted to cater for people with all disabilities, including those using wheelchairs. Outreach visits are provided for people who are unable to come to the Hubs.