Bridge Home from Hospital Service1 January 2017 - 31 May 2018

3 July 2018

By

Geoffrey Ocen, Chief Executive, The Bridge Renewal Trustand

Priyal Shah, Head of Integrated Commissioning (Adults), Haringey CCG

Overview• The service aims to provide practical and emotional support to

patients aged over 18 years old to return home safely from hospital on discharge, and settle in the community.

• This presentation provides information about activities delivered between 1 January 2017 to 31 May 2018.

• During this 17 month-period, we supported 848 Haringey patients aged over 18 years old (annual target 500; 17-month target 708)

• We have exceeded our target by 20%.

Hospital Home

Home from Hospital Staff Structure

Who we can helpResident of Haringey and aged 18 or over

Requiring discharge from Whittington or North Middlesex Hospitals

No longer requiring acute medical care

Would benefit from practical support at home but not including personal hygiene, domestic cleaning or laundry

At risk of hospital readmission if no support is currently provided

Worried about returning home, live alone or have no support from family or friends

What you will get from us

Practical assistance with: Essential food shopping (non-financial), Contacting appropriate services, Checking and topping up amenities, Collecting pension /

benefits / prescriptions

‘Check and chat service’ – telephone calls for the first 4 weeks following discharge

Accompanying patients home

following hospital discharge

3 home visits and up to 4 weeks of support

after hospital discharge

Help with making and accessing GP and other health and

social care appointments

The service encourages patients to regain their independence on returning home, by providing social and practical personalised support including:

Referral routes

• Hospital discharge or as part of a

period of reablement

• GPs , social services or community

health services.

• Integrated health and social care

services

• Self-referral or family referral

Contact details

By phone: 020 8442 7651 (Office)

Marcelle, Referral Coordinator

By email: homefromhospital@bridgerenewaltrust.org.uk

In person:

The Bridge Renewal Trust

Laurels Healthy Living Centre

256 St Ann’s Road

London N15 5AZ

Time: 10 am – 5 pm daily

How to make referrals or contact the service

Between 1 January 2017 and 31 May 2018, 848 Haringey patients were

supported (annual target 500; 17-month target 708)

Activity

Challenges faced

• Co-ordinating and providing integrated care across different agencies:– Ensuring consistent working relationships with Hospital

staff and partners– Appropriate signposting and referrals

• Language barrier– English as second language . – Recruited multilingual staff and volunteers and able to

successfully deal with the language barrier.

Case Study - Ms KB

• Referred from North Middlesex University Hospital

• Felt anxious about returning home on her own

• Needed assistance with food shopping and settling back home

• Alcohol and mobility problems (zimmer frame)

Ms KB,

71 years old

Lives alone

• Escorted home from hospital

• Shopping for food so she had something to eat that eveningDay 1

Hospital Home

Next 2 visits

Safe and independently living at home

Key safe in place

Wears pendant alarm

Regular podiatry visits arranged

Confident to have tea with neighbour

Outcome

Concerns noted and practical support provided

Discussed pendant alarm andkey safe with family members

Referral to Haringey Community Safety and Sound Service for pendant alarm and key safe

Foot problems noted Referral to podiatry services

Problems mobilising at home Re-arranged furniture make it easier to move around

Hoarding noted Referred to London Fire Brigade for free home fire safety visit

Living alone, possibly lonely Information on local services and community groups provided

‘I couldn’t cope with all this on my own. Thank you very much for your help’. She also said that we could ‘pop in to visit me for a cup of tea any time’.

Case Study - Ms KB

Discussion

• What improvements can we make in the way we work to make it more person centred and joined up?

• How can we best demonstrate that the service is supporting people to remain well and independent in the community?