The challenge

Care homes are usually not connected to NHS IT systems. Care home staff need to rely on telephone calls to local NHS services when they have concerns about a client. This takes them away from clients and can often mean they are in call queues for some time. Often they are admitted to hospital or community nursing teams come out to visit residents to provide care.


Leaflet – Digital Care Home

Brochure – Digital Care Home

Case Study – Digital Care Homes in County Durham

How does digital care homes work?

Digital Care Homes includes a range of products which allow care homes to interact with NHS services. These products are optional so the offering can be customised depending on local requirements.

All the products are designed by clinicians and developed to work with the existing workflow.

The Digital Care Homes range includes:

  • Digital referrals and remote monitoring (using the Situation, Background, Assessment Referral SBAR tool)
  • Video conference
  • Wound management
  • Undernutrition

Health Call products are designed to integrate with existing electronic patient records, which means that any data captured is integrated back into NHS records.

SBar digital referral and remote monitoring

The SBAR Digital Referral and Remote Monitoring tool allows care home staff to make electronic referrals directly to local NHS services.

Care home staff capture observational data using the Situation, Background Assessment, Recommendation (SBAR) model. The system then calculates a NEWS2 (National Early Warning) score which is then integrated back into the patient’s NHS care record.

Care home staff carry out remote observations such as blood pressure, oxygen saturation and temperature, whilst also providing details of their concerns. The system calculates the NEWS2 score based on the information provided. This information is submitted to clinical teams in the NHS so that community nurses can assess the client through a high quality electronic referral.

It was initially developed by County Durham Care Partnership – a collaboration of local authority and healthcare providers. They introduced the service across 115 care homes.

sbar digital referral and remote monitoring benefits

  • It integrates with the existing NHS patient record
  • Care home staff feel empowered
  • Clinicians are better informed when they receive a referral which helps them manage their caseload
  • Our evaluation found that there was a 30 per cent reduction in community nurse visits
  • Hospital admissions were reduced by 3.4 per home every month
  • It led to a reduction in inappropriate hospital admissions
  • Care home staff spent less time on the phone trying to make referrals which means they can spend more time with residents
  • Client’s families and friends felt more reassured that their loved ones are being well cared for
  • The data captured by care home staff is automatically populated into the patient’s NHS electronic record so there is no need for further data entry
  • Residents feel better cared for and more involved in their own care
  • The tool provides a full digital clinical audit trail

sbar digital referral and remote monitoring case study

Digital Care Home Case Study

Health Call’s Digital Care Home is a digital solution that enables trained care home staff to send observational data for clients to hospital staff. This means a clinical decision can be made regarding the client so that clinical teams can manage and prioritise patients, based on their observational data.

It also allows for routine observations to be provided which helps identify what is ‘normal’ for individuals or to detect early deterioration.

Care home staff use the SBAR – Situation, Background, Assessment and Recommendation tool. These observations are used to calculate a NEWS2 score (National Early Warning) which clinicians can analyse and determine the most appropriate next steps for that patient. This not only helps plan care for the patient, but also helps staff prioritise their caseloads.

The results are available to the clinical team in real time. The results are pulled through into the existing electronic patient record and are triaged appropriately.

Admissions to hospitals reduced on average by 3.4 per care home each month as a result of the project. It also helped to identify clients who should be in hospital sooner, making care for those people safer.

Sandra Smyth, a district nurse who has used the service said:

We will wonder why we did it any other way. The SBAR is effective for nurses to prioritise where they need to attend to ensure the best patient outcomes.

video conferencing

This allows NHS staff to have remote consultations with care home residents. It can help reduce the number of physical visits to a care home and may lead to fewer clients being admitted to hospital. The Video Conferencing tool may be used after a SBAR Digital Referral if the clinician wants to physically see the client.

Find out more about our Video Conferencing solution.

wound care

This tool takes clinical staff through a simple form which captures data relating to a wound. It takes them through a number of questions and supports clinical decision making. All data captured is integrated into the patient’s electronic record and it includes a feature to upload photos.

Find out more about our Wound Care product.


Our award-winning undernutrition programme improves the well-being of patients who are at risk of undernutrition, or who are already undernourished.

Our product allows NHS staff to monitor a patient’s weight, appetite and compliance with prescribed nutritional supplements. It reduces the need for home visits and outpatient appointments whilst supporting the patient and their carer to be involved in their nutritional health.

Find out more about our Undernutrition service.

Falls prevention service

Our home monitoring falls prevention service aims to reduce the risk of falls. Healthcare professionals are able to monitor their patient’s risk of falls using health indicators such as strength, balance and completion of home exercise plans.

Our service involves the patient receiving an automated phone call, where they are asked a few simple questions based around whether or not they have had any falls, how they feel about their balance and how they are getting on with their home exercise plan.

Find out more about our Falls Prevention service.

Diabetes remote monitoring

Care home residents identified by the district nurses as being appropriate for senior carers to administer insulin are added on the diabetes remote monitoring pathway. When the district nurses start the pathway, they set upper and lower parameters for the BMs.

Find out more about our Diabetes Remote Monitoring solution.

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As a result of Health Call Digital Care Home, I am called out less by the care staff when they are worried about a resident

Health Call Digital Care Home works with us and gets the information to where it needs to be without spending ages on the phone

Before Health Call, as nurses, we did not know what we were walking into, we just had been informed the patient was unwell. We now have good observational measurement and an outline from carers describing signs and symptoms.

The background information, such as how long the patient has been unwell is invaluable. It helps us as ANP staff to triage which patient we need to see first, this is especially important when there can be long distances between care homes.

When Mr X was unwell, I was able to reassure him and his family by recording his observations, once I have uploaded these and gave some background on how he was feeling, I received some feedback instructing me to take his temperature again and when to do this. He has recently finished antibiotics for a chest infection, and I thought it was starting again. The nurse came and prescribed a further course. Before Healthcall I would have had to either call for a GP or send him to hospital. Now he was able to be kept at home, where he and his family wanted him to be.


Leaflet – Digital Care Home

Brochure – Digital Care Home

Case Study – Digital Care Homes in County Durham