Southern Health NHS Foundation Trust have partnered with Age Concern Hampshire to run a Hospital to Home service.

It helps older people to be cared for at home to reduce their hospital stay, create beds for those who urgently need them and can prevent hospital re-admission.

Based on the rehabilitation wards at Alton Community Hospital, Petersfield Community Hospital and Gosport War Memorial Hospital, a hospital to home coordinator works to support the process of rehabilitation and discharge for patients and aims to reduce the likelihood of their re-admittance. 

Their main role is to establish a good relationship with patients and their families to enable them to return home as soon as possible after they are medically fit to do so.

They get to know each patient, talk about what matters to them, offer support with re-establishing a person’s independence and readiness to return home. They also work with the patients’ families to establish what practical support is required when returning home. The service supported 486 patients and their families last year. 

Staff help patients in other ways too, like sorting their finances out, arranging care packages for when they left the hospital, clearing out houses when they have become cluttered and unsafe. They organise therapeutic sessions – such as visits from dogs from the Pets for Therapy charity and holding a music appreciation group – with requests for anything such as Swan Lake to Chas and Dave.

Helen Callen chief executive at Age Concern Hampshire, said: “The service makes a meaningful difference, supporting discharge from the wards, ensuring that patients are supported on their journey through rehabilitation and discharge as they move from hospital to home, as well as improving time spent on the ward through activities and social interactions. 

“It provides support to contribute to patients’ rehabilitation, health and wellbeing in preparation for their discharge and actively identifies issues of patient concern regarding their discharge. Coordinators work with the ward team to address issues to make for a ‘good’ discharge and to prevent re-admission.

“Additionally, it provides information, signposting and referral to community support services if they are needed, making follow-up calls and visits after the patient has been discharged, to ensure continued safety, health and wellbeing once they are home.”

Paula Hull, director of nursing and AHPs for Southern Health, said: “Working with Age Concern Hampshire to provide this essential service on our wards is making such a difference in the recovery of our patients and freeing up medical and nursing staff; the hospital to home team provides advice and services to enable our patients be discharged and ensure they reduce the risk of being readmitted by continuing to support them at home.”

Founded in 1985, Age Concern Hampshire provide services to the older community of Hampshire. The charity currently deliver support at their are & Wellbeing centres throughout the county, as well as Help at Home, Information via our Information Hub, Foot care clinics, Hospital to Home Services, Community Information Volunteer Services and a variety of other activities.

For more information, visit: www.ageconcernhampshire.org.uk

Age Concern Hampshire
Centre Way
Locks Heath
Southampton
SO31 6DX

Tel: 01962 868545