Collaborative approach to hospital discharge improves patient outcomes

That is why commissioners are realising the significant benefits of working with housing associations, who have the homes, and support, to ensure a successful transition from hospital back into the community.

Home Group, for example, have been working with NHS trusts for more than 10 years to provide hospital discharge services. These are partnerships between us and NHS trusts to provide housing and social support to patients ahead of and during their discharge, to lift that burden away from healthcare staff.

In one instance in Northumberland, over the course of 12 weeks, our colleagues were able to work with a patient and his medical team to find a safe home in the community which he could be discharged to. That customer had been in hospital settings for more than 10 years because of his complex housing needs and readmissions. He is now thriving in his new home and regularly engaging with community support – something that had previously been a significant challenge.

Having ran hospital discharge services in Durham, Teesside, Norfolk and alongside Cumbria, Northumberland, Tyne and Wear (CNTW) NHS Foundation Trust, our teams have supported a wide range of patients with varying levels of need.

Our services began working alongside mental health wards due to the higher rate of complex needs and referrals from this patient group, but in the 10 years since we have expanded to work with patients from all types of hospital admission.

In a single year alone, our team supported more than 2,000 patients alongside CNTW NHS Foundation Trust.

For many of these patients, our involvement can be minimal. A patient’s home may simply have outstanding issues like damp and mould, which we can help support to get resolved. Or there may be issues around hoarding, for example, where our team can step in and assist with, as well as working with the patient and their medical team to help treat the behaviours which may have led to it – something their community care team can then continue and build on after the discharge and transition period.

But for others, their need can be more complex. Some patients may have entered hospital settings homeless, or since become homeless, or their existing home is no longer safe or suitable for them to be discharged into.

Rather than them being trapped in a hospital bed for longer than they need, our team is able to work with them to identify potential new homes which might be suitable. Being a large, established housing association certainly helps with this, as we have our own housing stock which we can consider using.

Our team are also very experienced navigating the local housing systems and processes too though, and so we will also support hospital patients to secure housing from local authorities and other providers, if it better suits their needs. For some, it may be that if the right home isn’t available at that moment, that temporary accommodation may be the best option, or a referral into supported living if they require more intensive support in the community.

The key for us is ensuring it meets the customer’s specific needs, and that they are involved in every step of the process. Achieving a hospital discharge is a great step for many of these patients, but it is just as important that they settle in the community and avoid a readmission.

Our team, the same one the patient has worked and built a rapport with while on the hospital ward, will therefore continue to work with the customer for the initial weeks of their transition into the community, allowing them to stabilise and retain a familiar face while they adjust to working with their community support teams.

Especially for those patients who have had long stays in hospital, this approach has ensured really positive outcomes and helped the patients to achieve goals in their independence that they previously didn’t think they were capable of.

On average, Home Group’s hospital discharge services have seen 60 fewer days spent in inpatient settings per customer, greatly improving their quality of life and directly tackling issues NHS trusts are facing around bed blocking.

It remains a collaborative approach too, and as such we are always looking to debrief and work closely with both the NHS staff and commissioners we work with, as well as the patients themselves, to learn where the service works best and where there are still opportunities to further support our customers.

Mark Bunting, transitional discharge team clinical lead at CNTW NHS Foundation Trust said: “The Home Group Team have become a critical service here at CNTW and I cannot see how we could continue to operate without them.

“They have transformed what we are able to do, and together we have delivered outcomes that otherwise would not have been possible.

“We worked on one particular complex case that NHS staff believe without Home Group the patient would still be in hospital as we simply did not know the barriers to overcome.”