How Sharon and the team are working to get people home from hospital

Meet Sharon Wells. She's our Discharge Matron at Oxford University Hospitals (OUH). While she's based at the Horton General Hospital and John Radcliffe Hospital, she works with teams across the entire trust to help people home.

Having worked at OUH for nearly 30 years, Sharon works with colleagues to oversee people going home from hospital every day.

She liaises with ward staff, nurses, therapists, health and social care partners, and patients and their families to ensure that people get the right care, in the right place, at the right time.

Let's hear from Sharon about her role.

"As you can imagine, no two days are the same in this job.

"Every day, the team and I oversee patients' journeys through our hospitals - either to home, or to a community setting. We all know that in most cases care closer to home is so beneficial for our patients. Care in familiar surroundings is not only more comfortable, but also helps people build up their independence more quickly, which is a really important part of their recovery.

"Once someone is admitted to hospital, we start looking at what their journey with us will look like, including assessing what additional care they may need to help them recover well at home. It can sometimes be really small, day-to-day things - making sure their food cupboards are stocked, the heating's on, and even something like making sure they have their door key.  You'd be surprised how many people come to hospital without one, especially if they're admitted in a rush.

"Sometimes there’s a much bigger picture when people need additional help to recover at home. We help plan additional care, which can look like home visits, physiotherapy, new equipment, or social work visits. We work with the Transfer of Care Hub team to make sure that a plan is in place, and how it will be carried out."

The hub is made up of staff from OUH, Oxfordshire County Council, Oxford Health NHS Foundation Trust, and community services, who all work together to get people home quickly and safely from hospital with the right support in place.

Since the hub was set up in January 2023, the average length of stay in hospital for people needing support on discharge has nearly halved, reducing from 10 to five and a half days. People's experiences of hospital discharge in Oxfordshire was recently included in a Healthwatch England article as evidence of the value of a good discharge process.

"We work very closely with patients and their families. Ultimately, we want people to feel safe and happy with their plans after hospital. Sometimes, especially after something like a fall, people can really have their confidence shaken and they're worried about going home - even going so far as feeling safer in hospital.

"We genuinely understand how that can happen - you're surrounded by people, there's always someone there to help. Now, by working in partnership with health and social care colleagues, home care can be more frequent and longer than some people may expect, which is often reassuring."

Sharon and the team work closely with colleagues at Oxfordshire County Council, who lead on social care. In the last year, the council's adult social care team has completely reorganised the way they work to support more people to return directly home from hospital more quickly, through the discharge to assess programme.

The service enables care and financial assessments to now take place at home, rather than on a hospital ward, by providing immediate short term home care on the day a patient is discharged from hospital.

Discharge to assess enabled more than 7,000 people to be moved safely out of hospital with additional support during 2024 - an increase of 23 per cent compared to the previous year.

Sharon also understands the importance of tailored care.

"Wherever possible, we want to tailor home care to a patient's individual needs. Throughout their time with us, we talk to them and their family about what works for them, what they want to achieve. That could be more mobility at home, or getting well enough to attend social events they used to before their time in hospital."

Sometimes, there may be occasions where people can't go home from hospital as quickly as they'd like.

Sharon said: "When there are times when people can't go home, we take a look at the situation and work to find out why that may be. Part of my job is to speak to all involved and see if there's a way of unlocking the situation - our ward staff are busy and won't always have time to see the alternatives or look at things in more detail, whereas I can dedicate my time to that and unblock any issues that might otherwise prevent people going home."

Ultimately, Sharon and her colleagues want patients to receive the best care, in the most appropriate place.

"Home care has come a really long way over the past few years. It's a chance to tailor someone's care, find out what their priorities are, and get them confident and recovered in their own space. Sometimes people will insist on care home support without fully exploring the home care options because they're not fully informed or nervous of home care - I will often say to those people: 'does this mean you never want to see your home again?', which broadens their perspective.

"Getting people care closer to home is one of the wider NHS' long-term goals, and we really support that. We are doing all that we can to make it a reality, while respecting our patients' wishes and ensuring everything is carried out as safely and considerately as possible."