Integrated care–Home Again service

Why not bring the Home Care providers into the hospitals to give families and patients the opportunity to plan for their own return home?

Accompanying the growth of retail shops and other services for the patient can be a Home Care store staffed to match visiting hours 7 days a week. The store should advise on all aspects of home care, telecare, live in care and even end of life. And it can provide assessment visits to people’s homes, recommending adaptations and aids for when the patient comes home.

This could be a very positive answer to the gap between the acute sector and primary care sector. The meeting of 2 systems in one building can be the missing link to the integrated care system that is talked about (the “Grail” for excellent individual patient care).

There is such a service being trialled in the Mid Essex Hospital trust, focussed on social service users and paid for by social services – since the Home Again service began there have been no fines for bed blocking because there are no blockers. For example 8 Patients last weekend were safely being cared for at home over the weekend rather than having to remain in hospital. Of course Wales don’t have fines but we do have blockers.

David Nicholson’s quote is 25% of all patients in hospital shouldn’t be there – here is a way to make sure that those patients who don’t want to be there can get back to heir own homes safely!

Can we set up a working party to champion this initiative?

Written by Justin Jewitt, Visiting Professor

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One Response to Integrated care–Home Again service

  1. Neil Williams says:

    I work for Care & Repair Cymru and we have a pilot in two counties in Wales that would significantly contribute and provide outcomes as indicated above. I include a brief description below and would gladly speak further. Hospital to Home Care & Repair’s ‘Hospital to Home’ scheme has been piloted and continued in two community hospitals in Conwy and Caerphilly along the following principles: • Early intervention for older person who is given an information pack containing housing options on admission rather than at discharge; • A caseworker visits the older person at the hospital bed; • There is time for the older person and family/carers to consider and discuss issues at the earliest opportunity; • To provide greater understanding of a range of services, including housing repair, in –house adaptation, local authority Disabled Facility Grants, home safety assessment, housing options and welfare benefit entitlement, that are part of a Care & Repair service; • Front line nurses and professionals involved in discharge decision making have greater awareness of Care & Repair services and what is available to support older patients; • Care & Repair agencies have funding for the Rapid Response Adaptations Programme (RRAP), and other minor adaptations schemes as a practical solution for small works of adaptation, repair and physical assistance (i.e. moving furniture); • Older person is visited by one agent, that opens up a housing-related care pathway, rather than dealing with a complex range of agencies; • The service provided is nationally branded, free assessment and good quality advice, low-cost best value solutions, reputable builders, management of works, quick, trustworthy and reliable.

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