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Home from Hospital help proves a lifeline

A Bradford district service which provides help and support to elderly and vulnerable people coming home from hospital is proving a lifeline.

The Home from Hospital (HFH) team, part of Carers’ Resource, supports people when they return home from hospital; making sure they have everything they need to stay well and independent, regain confidence and re-adjust to living at home, and avoid a return to hospital.

The service is funded by the three local NHS clinical commissioning groups (CCGs): Airedale, Wharfedale and Craven, Bradford City and Bradford Districts, as part of their joint aim to provide effective, patient-focused care closer to home. 

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It was first commissioned in 2012 and the service recently had a funding increase in January this year. It is part of the Better Care Fund - a programme spanning both the NHS and local councils which has been created to improve the lives of some of the most vulnerable people in our society by providing them with ‘wraparound’ fully integrated health and social care.

A wealth of evidence shows that patients make a better recovery if they leave hospital as soon as they are well enough to do so, provided they have the right support in place. 

The HFH team provides extra support to elderly people who have been discharged home from hospital following surgery, ill health, or an accident, so they can recover in the familiar environment of their own home.

The service offers flexible weekly visits to give emotional support and help with a variety of tasks such as finding solutions for shopping, providing nutritional information, help with benefits, form filling, reducing social isolation and promoting self-care.

Dr Nick Hayward, clinical lead for primary care at Bradford Districts CCG, said: “We are delighted with the results of the Home from Hospital service, which has allowed patients to be discharged sooner and make a swifter recovery. The service has also reduced the risks for patients who spend longer in hospital than is needed, such as infection, increased confusion and reduced mobility.

“By investing in services like this, which offer support to people in their own homes, we’re making sure people get the care they need while reducing the strain on hospital services. The success of joined-up care services such as these can be seen in some of the excellent patient feedback the service has received.”

Team members work with people to tackle a wide variety of issues which may be having a negative effect on their health and wellbeing. As well as screening for falls, pressure sores and depression and referral to other services, addressing low level social issues can also lead to better health outcomes and reduced hospital admissions.

Referrals to the service are increasing; in the three months from October to December last year there were 150 referrals from across the district – up 21% on the previous quarter, and an increase of 45% on the same period in 2015.

Patients were mainly in the age range 65 to over 90 years old, and all had several long-term health conditions including stroke, chronic obstructive pulmonary disease (COPD), diabetes, reduced mobility, cancer, anxiety and depression.

Shelley Marshall, HFH service manager, said: “The service has gone from strength to strength. The team is multi-skilled and provides a high quality service; supporting people with the things that are important to them, which means they have more choice and control.  Often it’s the simple things that make a huge difference but people don’t always know where to go for information or help.

“Helping someone to regain their confidence can greatly improve their quality of life and help them stay well and remain independent. Also, we’re able to give added value by supporting families and carers who are often under increased pressure when a family member becomes ill.”

Patients are reporting high levels of satisfaction with the HFH service as well as positive outcomes for health and wellbeing. In a recent survey, 95% of people said the help they received had made them feel less anxious, 100% would recommend the service to others, and 94% said it had given them lots of useful information.

The service helps people get better sooner and return to their own homes quicker, so freeing up hospital beds for people who need them. It is part of a range of local intermediate care services, including Bradford Hospitals’ Virtual Ward, which supports people to avoid hospital admission or to leave hospital as early as possible, while still needing additional, short-term care.


Case studyTeam’s support makes big difference to health and wellbeing

The Home from Hospital team made a real difference to a client’s life when they got involved after she had a fall and was struggling to cope at home, which was making her feel isolated and anxious and have low moods.

The team coordinated a package of support – both practical and professional, including visits and telephone support, an application for attendance allowance, referral to the council’s 24-hour Safe and Sound service, information about care services/providers and emotional support for the client and her family.

Since HFH got in touch, the client hasn’t had any more falls, can now afford to pay for home care thanks to benefits help and a physio has helped her become more mobile – all positive outcomes which have led to improved health and mental wellbeing, more self-confidence, better self-care and feeling less socially isolated.

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