Even in the first handover of the day, our Urgent Community Response (UCR) Team always have patient care at the forefront of their minds: "Next on the list is John, but he likes to be called Terry."

Sharing a name preference with the team may seem like a small thing, but to Terry it made all the difference when Specialist Practitioner, Kat Byars, went out to see him later that afternoon.

From a small detail like this, to the wider hospital picture, our UCR team are an essential part of #TeamCHFT. We've been getting to know more about them, what a day in their life looks like and how other colleagues can utilise them appropriately to support early discharge and prevent hospital admissions entirely.

Our UCR team are a planned and an unplanned service. Meaning they deal with referrals from both the hospital (planned) and the community (unplanned). The aim for all referrals is to see patients either within 2 hours, 24 hours or 72 hours, depending on urgency.

The first patient of the day was Margaret, who came through as an unplanned medical referral. UCR responds to these referrals within two hours. Advanced Clinical Practitioner (ACP), Alex Birnie (pictured front, middle), was assigned to go see her. After looking at Margaret's notes, she grabbed her equipment and left Dean Clough to head to the patient's home.

Twenty minutes later, Alex was performing a medical assessment on Margaret. The results of this assessment were used to decide which onward pathway Margaret would be placed on. These pathways can include:

• Medical intervention from the ACP or Specialist Practitioner for example, prescribing medication, advanced care planning or providing urgent equipment
• Organising for Margaret to receive care in her own home from others such as stepping up to Hospital at Home or other community services
• Or deciding that Margaret’s current level support at home was appropriate
• Admittance into hospital

Once the visit with Margaret finished, Alex was straight onto another referral which had come through.

Back at Dean Clough, Kat Byars (pictured front, right) was preparing to respond to a planned Home First discharge from hospital with patient Terry. She picked up the referral to better understand the situation she would be walking into and then headed off to his home.

Once there, Kat spent time with Terry and his wife getting to know them both, easing their concerns and learning more about what their needs would be going forward and how the UCR team were going to support. An important area of her assessment was observing how Terry moved around his own home, which is just one part of the in-depth holistic assessment that is completed on all home first visits.

This is a crucial part of the UCR service and is labelled as wraparound support - Kat had assessed this patient at home under a Discharge to Assess approach, determining what support Terry needed at home. UCR has Rehabilitation Assistants who can support people at home up to four times a day with meals, medication and personal cares with a view to helping them regain their independence. This means that the team member visiting is assessing their abilities to manage daily tasks in their own home, because this can be entirely different to how they presented in a hospital environment. Once they have this period of assessment at home, the UCR team can then put them onto the correct onward pathway.

Our UCR team are helping prevent hospital admissions and supporting early discharge. By going out to see patients, performing examinations and offering medical support if needed, it is helping to keep these patients out of hospital entirely.

Early discharge is also possible because our UCR team can perform care, historically done in hospital, inside the patient's own home instead and support this to happen earlier so that patients can recover at home

Deputy Team Manager, Amber Ballard, said: "For me, this team is true patient-centred care. We're keeping them in their own environment and listening to their wishes to remain out of hospital.

“We work with patients, families and carers to enable them to remain at home, recover and regain independence as much as possible.”