Multidisciplinary team helps patients get home from hospital this winter

A multidisciplinary team who provide care and support to patients when they leave hospital have launched a new initiative to help more people regain their independence and get home quickly and safely.

The Home Assessment Reablement Team (HART) are working on a therapy-led 'discharge to assess' initiative which is aimed at people who do not need to stay in hospital, but who need extra support in the short term to enable them to go home.

The initiative helps identify these patients earlier, meaning they spend less time in hospital and are then assessed in their familiar home environment to help plan for both their short and longer-term needs.

Some of the support HART offers includes enabling independence in daily life, like helping people to learn to wash and dress independently again, and cook their own meals.

Following a trial at the Horton General Hospital in Banbury earlier in 2019, the initiative is now also underway at the John Radcliffe Hospital for patients living in the centre of the city, and will be rolled out across Oxfordshire by the end of 2019.  Part of a Trust-wide programme with a focus on continuous improvement, the initiative will help support patients through the winter months.

To date, HART staff have supported 348 patients through the 'discharge to assess' initiative. 257 of them have since been discharged from HART's care, with 60 percent of these people now living fully independently following their treatment, and the other patients receiving ongoing support in the community.

One patient who benefited from the service is Ronald Sonneborn, 82, who lives in Headington. He was admitted to the John Radcliffe Hospital earlier in 2019 after he had a fall and fractured his right shoulder. He was treated at home by the team as part of the 'discharge to assess' initiative, including help with washing, dressing, and providing therapeutic support with equipment and exercises to aid his recovery.  Over time, his confidence improved and he now takes 20 minute walks every day, and he is managing his own care and ongoing recovery with physiotherapy.

Ronald said: "After I had my fall, my confidence took quite a knock. You don't realise just how much you use something like your shoulder until it's injured.

"While it's hard being injured, being discharged more quickly and receiving treatment at home made things so much easier for me. The team helped me feel secure, and were very professional and caring and are just lovely human beings. The whole initiative is really brilliant.

"I'm still on the mend, but I'm very grateful to the team for their help in getting me started and making me feel more comfortable at home."

Sam Foster, Chief Nursing Officer at the Trust, said: "This initiative is a really wonderful development for HART. The work they do is so valuable for our patients, and by changing the location that we make decisions about ongoing care needs to a person's own home rather than in a hospital ward, we can make sure more people are confident and happy in their homes following discharge from hospital.

"Once hospital care is complete, many people want to be back home as soon as possible, which is completely understandable. Being in hospital for longer than needed often leads to a deterioration in people's general condition, and can even increase their long-term care needs.

"By helping people regain their independence and continuing our 'home first' approach, the team can continue to deliver safe, effective care and support in the most appropriate and often happiest setting for our patients."

Stephen Chandler, Director of Adult Services at Oxfordshire County Council, said: "We're delighted that HART at Oxford University Hospitals NHS Foundation Trust have taken this new 'discharge to assess' approach forward.

"Patient safety and care is at the heart of all that our organisations do, and by bringing treatment closer to home we can make sure that patients are happier and more confident in their own environment, which is an essential part of a successful recovery."

Pictured: Ronald Sonneborn at home in Headington