We have been working with local partners to launch a scheme called Home First which helps people return home from hospital sooner after an inpatient stay.
The scheme enables patients to be discharged once they are medically fit, where it is safe to do so. Before the patient leaves hospital, a social care case manager from the Home First team carries out an initial assessment.
Once the patient has been discharged they are visited by an Occupational Therapist (OT) within two hours who assesses their needs.
This could be some equipment to help the patient move around, a carer to help them in and out of bed or meal preparation for the first few days home, or help from the voluntary sector with food shopping or medication collection. The OT ensures everything is in place to support the patient at home either the day they return home or the following day if this is more appropriate.
Case study: Mr G
The local social care team were preparing for his discharge but Mr G, being eager to return home, discharged himself at short notice. The social care team were concerned there was not adequate support at home but wanted to support his independence, so they contacted the Home First team who called round to see Mr G within two hours of him discharging himself to check he was safely home.
Having had good communication with the medical staff on the ward, the Occupational Therapist (OT) had thought ahead and picked up some useful equipment on the way to see him. On arrival, the OT found that Mr G’s living conditions were not conducive to his recovery: his only bed was a downstairs sofabed; there was evidence of damp; and the walkway to the bathroom was obstructed, which presented a risk of another fall.
During the assessment, Mr G agreed to have help from the district nurses and for a hospital bed to replace his sofa bed. The OT, with agreement from Mr G, also made a referral to a community physiotherapist and Swale Borough Council’s Staying Put handyperson service. A member of the Staying Put team visited Mr G the same day to offer help with making the walkway to the bathroom safe and reduce Mr G’s chance of falling again.
The Staying Put team removed a dangerous cooker, washing machine, microwave and fridge; and with access to charitable funds, received a donation to replace the items they had removed.
Mr G also explained he was concerned about being able to access his money to pay his rent. He accepted a referral to Age UK who helped him review his finances and identified Mr G as eligible to receive some financial support.
Mr G also accepted assistance from social services who arranged for carers to visit three times a day to help prepare meals which means he can now live in his own home and retain a better level of independence whilst feeling supported.