Hospital to home service supports older people to leave hospital and reduces re-admission

31 May 2023

Southern Health NHS Foundation Trust have partnered with Age Concern Hampshire to run a Hospital to Home service helping prepare patients to return to their home after a stay in hospital. The service also helps older people to be cared for at home to reduce their hospital stay, create beds for those who urgently need them and can prevent hospital re-admission.

Based on the rehabilitation wards at Alton Community Hospital, Petersfield Community Hospital and Gosport War Memorial Hospital and older persons mental health wards at Western Community Hospital and Gosport War Memorial Hospital, a hospital to home coordinator works to support the process of rehabilitation and discharge for patients and aims to reduce the likelihood of their re-admittance.  Their main role is to establish a good relationship with patients and their families to enable them to return home as soon as possible after they are medically fit to do so. They get to know each patient, talk about what matters to them, offer support with re-establishing a person’s independence and readiness to return home.  They also work with the patients’ families to establish what practical support is required when returning home. The unique part of this service is that the team continues to support the patient when they have returned home by addressing any issues, they may have which may prevent them from staying at home and signposts them to support in their local Communities.

The service has supported 486 individual patients and their families during 2022.

Malcolm, a patient from Gosport was able to visit his wife in a care home during Covid-19, with the support of a hospital to home co-ordinator who made all the arrangements.  He then received assistance in getting all the equipment he needed to be discharged from hospital himself and enable him to return home.  He now has wellbeing calls and a few home visits and is now joining a local men’s shed scheme to help him make new friends and get more active in the community.

“I am extremely grateful to the co-ordinator for arranging for me to visit my wife, it put my mind at rest that she was being well cared for and I was happy to be able to return home knowing I had support around me should I need it.”

Staff help patients in other ways too, like sorting their finances out, arranging care packages for when they left the hospital, clearing out houses when they have become cluttered and unsafe. They organise therapeutic sessions – such as visits from dogs from the Pets for Therapy charity and holding a music appreciation group – with requests for anything such as Swan Lake to Chas and Dave.  The joy that patients get from such activities really helps them socialise with others and have a focus in their weekly routines.

Helen Callan Chief Executive, Age Concern Hampshire says “the service makes a meaningful difference, supporting discharge from the wards, ensuring that patients are supported on their journey through rehabilitation and discharge as they move from hospital to home, as well as improving time spent on the ward through activities and social interactions.

It provides support to contribute to patients’ rehabilitation, health and wellbeing in preparation for their discharge and actively identifies issues of patient concern regarding their discharge. Coordinators work with the ward team to address issues to make for a 'good' discharge and to prevent re- admission.

Additionally, it provides information, signposting and referral to community support services if they are needed, making follow-up calls and visits after the patient has been discharged, to ensure continued safety, health and wellbeing once they are home.

Paula Hull, Director of Nursing and AHPs for Southern Health comments “Working with Age Concern Hampshire to provide this essential service on our wards is making such a difference in the recovery of our patients and freeing up medical and nursing staff; the hospital to home team provides advice and services to enable our patients be discharged and ensure they reduce the risk of being readmitted by continuing to support them at home.”

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