Home For Christmas: Do you need additional support at home following discharge?

The Trust is determined to make it a happy Christmas for as many patients as possible by enabling those who are medically fit to get home to spend the festive period with friends and family.

We know that recovering in your own home has many benefits, but at the same time, there may be additional support required. That’s where Rebecca Ioannou. Transfer of Care Hub Clinical Lead Therapist and her dedicated team come in.

There are wide range of services for all patients, and Rebecca will work to ensure that everyone gets the support they need to continue their rehabilitation at home.

“We know that home is best for our patients and we know that patients are able to be to recover better in their own environment,” says Rebecca.

So what are the services that might be available?

Home First
Rebecca says: “One of our services is called Home First whereby we get a patient at home and we assess them in their own environment and then we look at the package of care they might need or if they might need equipment. Home First consists of nurses, occupational therapists, and physiotherapists, so it’s a really good MDT team. We are looking to increase the service and hopefully we’ll get more allocated slots to get more patients home on that pathway.”

ESD (Early Supported Discharge)
Rebecca says: “This is a service whereby therapists can progress that patient at home so they are never left without any follow-up so they can have a social worker follow up within three days, as well as that therapy input so a really good full assessment within their own environment.”

Home To Assess
Rebecca says: “This is basically a package of care at home. We get the patient home and we get a package of care in place and that is assessed within three days of that patient being home, by a social worker, just to see that it’s appropriate for that patient. If there’s anything else that we need to put into place, like the the therapy that you can have at home, then the ESD will get involved, which is an MDT team whereby the therapists come and progress you in your own environment.”

Rapid Response
Rebecca says: “This is a service that can provide alternate care provisions and they can also prevent hospital admissions and facilitate early discharge from the hospital which is obviously excellent for our patients.”

The Falls Team
Rebecca says: “If a patient has had a fall at home we can get this team to go in to prevent any further falls and prevent any hospital admissions in the future. So this is a therapy team that can come and prevent the falls at home.”

Neighbourhood and EPC Care Teams
Rebecca says: “This is a multi-disciplinary team of consultants of pharmacists, of well-being physiotherapists, occupational therapists which can support you at home so that hopefully you will remain at home and not return to the hospital.”

Community Frailty Service
Rebecca says: “If you have a long-term condition, that which can include frailty they can have a 12-week input and provide you with a care plan.”

In addition to all these services which can help patients get back in their own environment in a safe and timely manner, the Transfer of Care Hub also work with Age UK and the Red Cross to look after additional needs, such as transport or food and well-being services.

Rebecca understands that leaving hospital can sometimes be a time of uncertainty, but the services that her team can support you or your family member through that journey.

“These services will enable patients to be discharged in a timely and safe manner and also increase the flow throughout the hospital to ensure that you know patients are going home, but that we also have beds available for patients to come into who need that acute hospital input,” she said.

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