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Hospital At Home model delivering results


An innovative programme aimed at making the ‘home’ the hub for delivering health and care for our elderly population across the Western Trust area has already delivered impressive results since its launch in January this year.

The “Hospital at Home” service, which was developed in the middle of the COVID-19 pandemic, has received a high level of support from the public as it seeks to provide support to Care Homes.

Since January patients have been able to receive treatment and ongoing care in their own homes, removing a great deal of stress and inconvenience, which had been a particular cause of concern for patients during the COVID-19 pandemic.

The programme has been earmarked as a key element in the future regional model for Intermediate Care as well as the ‘Enhancing Clinical Care into Care Homes’ regional initiative in keeping with local needs, Pathfinder engagement feedback and regional policy.


Speaking about the early success of the Hospital at Home Project, Professor Monica Monaghan, Western Trust Consultant Cardiologist explains: “I am delighted to be involved with the Hospital at Home initiative which aims to transform the care of our patients by creating an alternative pathway for the treatment of those who are acutely unwell.

“We recognise that we have an increasingly elderly population and patients who remain in hospital for what can be extended periods of time than we would like and thus are at increasing risk of hospital acquired infections, loss of their confidence and social connections with their family and local community.

These concerns are very real and the Western Trust has developed the Hospital at Home programme with this key consideration in mind. Amongst older patients, many of which may feel anxious and distressed being away from their home environment, we often see an increase in stress. Patients too can experience an increase frailty and be at increased risk of delirium and falls.”

Explaining the “Hospital at Home” model of care

In November 2020, a Hospital at Home Development Group was formed. With support from the South West Acute Hospital Medical team, Pharmacy and the Rapid Response Nursing team a pilot hospital at home service was established on 14 December 2020.

This initially involved working with 4 Care Homes in Enniskillen, including, Millcroft Care Home, The County Care Home, Meadow View Care Home and The Graan Abbey Nursing Home.

Through this model of care the team assess and treat residents in these Care Homes to avoid the need to attend Emergency Department and an admission to hospital.

Due to the initial success of the programme it is the intention of the Western Trust’s is to expand the Hospital at Home service, over time to all of Fermanagh and West Tyrone, in keeping with the Pathfinder vision.

Dr Kate Ryan and Dr Rizwan Haq, are the Speciality Doctors for the service and they are supported by the Rapid Response Nursing team in Fermanagh.  Clinical Leadership to the service is provided by Dr Monica Monaghan, Consultant Cardiologist South West Acute Hospital.


The Western Trust will deliver services in line with an Integrated Model for Prevention & Management of Chronic Disease (informed by the King’s Fund model), with greater emphasis to be placed on developing and enhancing Intermediate Care services.

Intermediate Care services will act as the bridge at the transition in a person’s life, in particular from hospital to home and hospital avoidance, from illness or injury to recovery and independence with a strong emphasis on providing personalised health and care to the service user in their own home or usual place of residence.

This is in line with regional strategic direction which is to have effective integrated services organised around the needs of individual people and provided at home, avoiding the need for hospital admission and to support safe discharge from hospital.