Community Support Programme For Early Discharge
Each month an average of 26 East Lothian patients are medically well but are unable to leave hospital because they required care which could be provided.
However, patients with rehab potential don’t always need high levels of support. By providing community volunteers, partnering with the third sector, and building social capital in the East Lothian supported care pathways, home assessment and rehabilitation work programmes, this project aimed to:
- reduce unnecessary hospital admissions and readmissions within 28 days
- increase self-managing of care
- reduce unmet need for care
- reduce the number of people delayed in hospital
By focusing on prevention, non-medical and low-level practical support, at points in a person’s life where a short intervention could restore or avoid a loss of independence and confidence, and reduce the risk of a longer stay in hospital or hospital re-admission people were:
- supported to return home, to their community and retain independence in a way that was safe
- assisted in lower reliance on care services and to better maintain their own health and well-being
Funding from the ihub was used to cover staff and volunteer marketing, training and research.
- What was the approach?
The STRiVE team worked in partnership with health and social care teams through agreed referral and information pathways, principally with the Short Term Assessment & Rehabilitation Team (START) on early supported discharge.
Everyone receiving the Supported Home Assessment and Rehabilitation Service was offered volunteer and community services support as an integral element of assessment.
This support contributes to the National Health and Wellbeing Outcomes by ensuring that people:
- were actively encouraged and supported to participate in their communities and participate in activities that could improve their own health and wellbeing
- were supported and encouraged to look at what they could do rather than what they couldn’t do, promoting their independence
- people felt listened to, treated with dignity, supported responsively and reliably
- people were given more information about what was available in their communities, services and advice
“It’s grand this aftercare, you don’t feel like you’ve just been left.”
The initial target was five, but a total of fifteen volunteers were recruited during the project. Their induction and training covered: boundaries, confidentiality, data protection, support for volunteers and ongoing contact, expenses, endings, protection of vulnerable adults, equality and diversity, health and safety, and protection of vulnerable groups.
The Project Worker (or Volunteer Co-ordinator) meets with the person in the hospital / home to discuss:
- how the service works
- how the service can assist them
- what they would like to achieve (in terms of short and long term goals)
Having a ‘good’ person-centred conversation and clear communication with patients, to help them engage in activities they considered important, and to assist them in regaining control and offering informed choices was crucial.
In addition to daily telephone contact, support from volunteers can be:
- practical assistance for tasks such as shopping, cooking, or gentle exercise
- one-off to attend appointments
- assistance to fill in forms or help navigate their way around services
- signposting to local support groups or agencies who can best meet their needs
- assistance to connect with groups / neighbours in local community
STRiVE as the operational lead, ensured that:
- Clear guidelines and boundaries were identified and agreed for the volunteers and the patients receiving support. The recruitment and selection of volunteers progressed and was in line with recognised safer recruitment guidelines. Provided regular supervision, support and training events for volunteers.
- Worked in partnership to identify, register and support eligible patients to achieve their goals. Assessed and promoted self-management to patients. Provided support, and links to the project and the opportunities within people’s communities. Regular reviews of discharged patients
- Identified and matched suitable volunteers to identified patients
- What was the impact?
Since October 2018 the team have visited all patients identified with potential for rehabilitation, and offered them support from the service or volunteers. Of the 95 referrals received 89 accepted and received 324 hours of additional support provided by the Community Support Volunteers.
Volunteer support has covered:
- one to one meetings, including signposting and form filling
- initial discharge support (meeting and agreeing outcomes, and community re-engagement)
- independence, confidence building, and supporting mobility
- wellbeing checks
Throughout this project the goal was to make a difference to the patients and their lives. Feedback questionnaires identified the following outcomes for patients:
- 72% returned home from hospital sooner
- 97% felt they had more access to support and advice at home
- 92% felt safe, secure and supported
- 79% felt wanted and less isolated on discharge
- 84% had an increased sense of self worth
- 74% felt they had an increased sense of purpose in life
- 89% felt they had more confidence to manage daily tasks
Feedback shows patients and their families value the volunteers support.
Encouraging and supporting patients in self-management, and supporting them through the community has improved the quality of their lives and allowed them to integrate back into the community safely.
- What was the learning?
- Using appropriate language, including plain english, for both volunteers and service users.
- The need to adapt and change quickly is essential for person-centred support.
- People appreciate the support to self-manage, and retain independence and confidence.
- Signposting to community assets and information services is equally important.
- Recruiting, retaining and training volunteers is in itself a full time job, assessing / speaking to patients is another.
- Admin support is essential for volunteer recruitment, organising patient visits and following up requests, producing newsletters and communications.
- Good reporting is essential.
- Working with occupational therapists and physiotherapists provided an insight to the ‘can do’ approach for patients.
- Pre- and post-service questionnaires should be short and easy to complete.
- Flexibility is essential. Many families’ can’t see you during the normal working day. The same applies to volunteers, meetings and training.
- Families would benefit from a one-stop-shop from an independent organisation to talk about their concerns, worries and how to claim what they or their loved ones are entitled to.
Patients often don’t know what is on in their own community and the “What’s On” guide has been a useful tool for encouraging people to talk about their interests, and what they would like to do.
People do not know what they are entitled to or services available to them because the statutory authorities don’t tell them, aren’t as proactive as they should be or are simply unaware of the services in East Lothian.
This project highlighted how a Community Link Practitioner could be used within a hospital and community setting through the addition of volunteers.
The ihub have been essential in the learning and providing advice to this project, particularly around statistics, outcomes, and in building a logic model.
- What are the next steps?
The team are looking to secure further funding for the project outside of the Health & Social Care Partnership. If successful they hope to use this to spread the project over all of East Lothian with the START team.
The learning and synergy of this project in relation to the Community Links service would benefit many patients in a hospital and community setting in other areas.