Patients avoided 7,500 nights in hospital and the NHS saved at least £2m to be reinvested by choosing a tailored Somerset help at home scheme.
The pioneering ‘Homefirst’ scheme, which has been jointly developed by the County Council’s adult social care team and the county’s hospitals, reduces hospital stays by up to 10 days by offering patients the opportunity to finish their therapy out of the hospital with tailored help from professionals.
The common sense approach – with the help of new collaborative teams – means patients can finish their therapy out of hospital, with NHS and social care staff working alongside independent care providers.
Homefirst provides a number of pathways offering varying levels of support to patients, with the ultimate aim of getting patients back home and back to their normal standard of independence as soon as possible.
The NHS’ long term plan, unveiled last week, said the NHS will increasingly be more joined-up and coordinated in its care, breaking down traditional barriers between care institutions, teams and funding streams; joining up health and social care services is central to the plan’s delivery.
In Somerset, instead of waiting to complete assessments, such as walking the ward, in a busy unfamiliar place, people can be discharged home at the right time and get support for important tasks tailored to their home enabling a quicker recovery.
In just over a year, Homefirst helped 2,000 patients leave hospital up to five days earlier, avoiding 7,500 nights in acute hospital beds. Along with other schemes, reducing overall delayed discharge in the county by 75 per cent from 3,500 bed days lost per month to 800.
Jointly funded by the council and the NHS, (Musgrove Hospital, Yeovil District Hospital and Somerset Partnership Trust), Homefirst started in September 2017 and brought physios and occupational therapists from the hospital and community services into a close-knit team with social care providers.
Tim Baverstock, who led the scheme for Somerset County Council, said: “We’ve found that all it can take to avoid a long hospital stay is a frank conversation with the patient and family to learn more about the benefit of being at home and how they can manage and recover with the right support.
“If someone starts to recover they often want to go home and previously paperwork and assessments could have meant waiting weeks. But while the patient waits their mobility and independence reduces and causes frustration – a person over 80 who spends 10 days in hospital loses 10 per cent of muscle mass equivalent to 10 years of ageing. We wanted to bring an end to that.”
The hospital therapists helped train the social care providers in different techniques so they can do more with patients to help them regain independence faster. These social care providers have enhanced their role and become a crucial part of the health and care system’s efforts to get patient’s home sooner with better outcomes.
Once home, they help complete the patient’s rehabilitation with daily visits until they have regained their independence or have a suitable, longer-term care plan in place. This might include therapy to help with mobility issues or to help recover their ability to dress and cook independently.
The team sees patients on the wards at both of Somerset’s acute hospitals, involving families in discussions about when a patient is ready to go home and liaising with medical, nursing and therapy staff to speed up the process where appropriate.
Across the NHS, 14 Integrated Care Systems (ICS) and many Sustainability and Transformation Partnerships are seeing NHS and local government join forces to pool resources and budgets and simplify systems for the patient across primary and secondary care.
The Homefirst Scheme is within Somerset STP and is an example of this integrated working.
Dr Karen Kirkham, NHS England’s National Clinical Advisor for Primary Care, said: “As we now progress the long term plan for the NHS it is common sense schemes like this which will get the best care for patients and make the best use of every penny. By finding out more about a patient’s circumstances at home we can tailor the care they get.”
Tim added: “We’ve been working closely with hospital and social care colleagues to transform the culture so decisions are about personalising care, talking to families and setting up the right support as fast and as close to home as we can.”