essential information for: community-based social workers ... · included moving furniture,...

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This leaflet is for community- based occupational therapists and social workers. It contains information about how older people’s housing and support can be considered as part of the hospital discharge process and is part of a lar g er r esour c e pack containing leaflets, factsheets and checklists for different professional sectors involved in the discharge process. Community-based social workers and occupational therapists Essential information for: Community-based social workers and occupational therapists Hospital

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Page 1: Essential information for: Community-based social workers ... · included moving furniture, repairing trip hazards (such as loose carpets), moving a bed downstairs, fitting grab rails

This leaflet is for community-based occupational therapistsand social workers.

It contains information abouthow older people’s housing andsupport can be considered as partof the hospital discharge processand is part of a larger resourcepack containing leaflets,factsheets and checklists fordifferent professional sectorsinvolved in the discharge process.

Community-basedsocial workers andoccupationaltherapists

Essential information for:

Community-basedsocial workers andoccupationaltherapists

Hospital

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Older people are being discharged from hospital followingtreatment sooner than in the past. The suitability of theirhome environment and availability of practical support canmake or break their successful and timely discharge and isat least as important as their medical and social care,following discharge.

There are a range of services available to people who are ready to be discharged from hospital that will help ensure that they can return to a home situation that will aid, rather than hinder, their recovery. These range from community-based ‘home from hospital’ services, to handyperson services that can complement services offered by community-based occupational therapists and social workers (see Factsheet 1).

CASE STUDY

Handyperson Services provide older and disabled people with much valuedpractical help with ‘odd jobs’, small building repairs, minor adaptations suchas the installation of grab rails and temporary ramps, as well as offeringhome safety and energy efficiency checks.

A National Evaluation of Handyperson Services, commissioned by theDepartment for Communities and Local Government 1, concluded that “Theyoffer an important safety net for older people, and they also enhance theeffectiveness of health and social care provision through the delivery of oftenvery simple and very low cost interventions” and that they offer value for money.In was noted that “the work undertaken by handyperson services is related toreducing risks and hazards and improving people’s safety and well-being in theirhomes” and hence supports the preventative agenda.

Handyperson Services Handyperson Services

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Did you know?Housing adaptations can reduce the cost of home care by £1,200to £29,000 a year 2.

Ambulatory care-sensitive conditions (ACSCs) currently accountfor more than one in six emergency hospital admissions inEngland, costing the NHS £1.42 billion each year. Effectivemanagement and treatment could reduce the incidence ofhospital admission by 18% (potentially saving £238 million) if all local authorities performed at the level of the best-performing local authorities 3.

Nearly 80% of all 30-day emergency readmissions in Englandfollow a previous unplanned stay in a hospital; nearly half returnwithin 7 days of their initial discharge 4.

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Key actions for community-based occupational therapists and social workers

In generalIf someone is going into hospital forelective treatment, start planning forhospital discharge prior to admissionand take into account an individual’shousing circumstances at every stage.Where possible spend time early on toproperly understand individuals’housing and support needs.

Many areas have effective ‘Home fromHospital’services in place run by voluntaryagencies. Familiarise yourself with the keyhousing and welfare benefit contacts inyour local area (see Factsheet 2).

Many older people are discharged intocare homes, despite an expressed wishto return home. In many cases, suchindividuals could return home safely ifkey agencies coordinated their effortsto meet the individuals specific needs.For example, telecare is increasinglyused to help people with dementia tolive in their own home.

Before admission – for elective stays

If you are already working with an older person before they go intohospital, ensure that you have up todate information about their housingcircumstances (see Checklist 1).

This will allow you to make earlyjudgements about patients’ ability tocope when they return home, and toget a picture of factors that mighthave contributed to hospital admission– such as damp housing.

Complete the Template for assessing a patient’s housing situation andforward this information to thehospital to ensure it reaches personnel dealing with both theindividual’s clinical care and theirdischarge planning.

Identify any housing-related barriersthat could impede a patient’s progress towards their recovery goals and include potential solutionswithin their Care Plan.

Signpost older people and theirfamilies to places where they can gethelp and good advice with housingproblems (see Factsheet 1).

If an individual has a rapidlydeteriorating condition, and is likely to be entering the terminal phase, there are often housingimplications. A variety of agencies (see Factsheet 1) help families to make temporary arrangements suchas making a downstairs room into a bedroom.

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CASE STUDY

Age UK Mid Mersey piloted a hospital discharge service with a focuson housing. An occupational therapist carried out home visits withpatients before discharge.

The patients were involved in identifying changes needed, whichincluded moving furniture, repairing trip hazards (such as loosecarpets), moving a bed downstairs, fitting grab rails. Age UK’s localhandyperson service carried out the tasks quickly and gave the olderperson appropriate information and advice. Discharges were timely andto a safe environment.

Age UK Mid Mersey Age UK Mid Mersey

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Discuss patients’ housing situationsand options with them, their familiesand carers, so that they can makeinformed decisions and arrange fornecessary works to be carried out in atimely fashion. If they are at the pointof having to take significant decisions,for example to move house, provideaccess to specialists who can help them to consider their options (seeFactsheet 2). It may be appropriate for the patient to move into temporaryaccommodation to provide time forsuitable accommodation to be secured.This might coincide with a period ofreablement and rehabilitation.

Emergency admissionsIf you have worked with the individualpreviously, and are informed abouttheir emergency admission, transferany existing information about theirhousing situation onto the Template for assessing a patient’s housing

situation and forward to the hospital-based contact to ensure it reachespersonnel dealing with both theindividual’s clinical care and theirdischarge planning.

Whilst in hospitalThe more that can be planned beforeadmission, the less the chance ofdelay in discharging the individual.It’s preferable to get a ramp in placewhilst the individual is in hospital than a week after discharge.

Fact: The occupational therapyaccident and emergency service atRoyal Cornwall Hospital providesseven day cover. This change madeincreased savings on admissionavoidance, and initial screening ofpatients who had fallen, andincreased efficiencies indischarging patients to theirhomes within 72 hours 5.

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If an older person is a tenant you willneed to liaise with the landlord if aidsand adaptations are required beforedischarge. The College of OccupationalTherapists and Housing Corporationco-publication Minor AdaptationsWithout Delay provides practicalguidance for housing associationsinvolved in fitting ‘minor adaptations’for tenants, such as stair rails. Itprovides technical specifications andexamples of good practice. A localhome improvement agency should be able to provide advice aboutaids and adaptations for privatetenants and home owners. If there is no home improvement agency in your area, the local authorityhousing or environmental healthdepartment should be able to help (see Factsheet 1).

Liaise with hospital basedprofessionals to achieve a smooth discharge.

If it appears that an older person isisolated, with no one to help withpractical tasks such as walking the dogor helping with gardening, arrange areferral to local ‘home from hospital’services (see Factsheet 1) as well asreferring them where necessary tolocal authority community nursing andadult social care for ongoing support.

Post dischargeContinue to liaise with local hospitaldischarge voluntary schemes to ensurea co-ordinated and seamlessdischarge process.

If you and your community andhospital-based colleagues take apatient’s housing circumstances intoaccount, and make arrangements in atimely way, there should be no hold-ups due to unsuitable housing. Evenwith the best laid plans difficulties dosometimes arise so wherever possiblecheck that the patient is returning toa home that will aid their recovery,before the hospital discharges them.

Where post-discharge day or outpatientconsultations are planned, whereverpossible check for any changes in thepatient’s personal circumstances andany impact on housing that can helpfacilitate their recovery.

Preventing readmissions:An independent evaluation of oneBritish Red Cross hospital dischargescheme offering personalised,flexible support found that only 3%of service users were readmitted inthe six months following discharge,compared with NHS Trust’s figuresshowing a 12% readmission ratewithin 28 days for the same period.

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REFERENCES:

1 Supporting hospital discharge and reducing readmissions: A British Red Cross briefing.

2 Heywood F et al. Better Outcomes, Lower Costs ODI/DWP 2007.

3 Kings Fund. Emergency hospital admissions for ambulatory care-sensitive conditions. April 2012.

4 Analysis based on 2009/10 figures. Taken from Sg2 Service kit Reducing 30-Day EmergencyReadmissions, June 211.

5 OTN May p46.

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ChecklistHave you familiarised yourself with the key housing and welfarebenefit contacts in your local area?

Do you routinely collect information about patients’ homesituations as part of routine health and care assessments?Have you passed this on to the relevant person at the hospital, providing you have permission to do so and thepatient’s agreement?

Are there any housing-related barriers that will prevent thepatient from achieving their health/care goals? (See Checklist 1)

Have you involved housing-related agencies operating outsidethe hospital in discharge and care planning for the patient?

Does the patient and/or their family or carer know andunderstand all the available housing-related options to helpthem to recover and live post-discharge? Do they know what itwill cost them and have they been given payment options?

Have you considered all the options for helping an older personto live independently, before making a decision to advise themto go into care?

Does the patient have someone to meet and greet them onreturn home and ensure that they have sufficient food andheating? If not, do you know about local agencies who may beable to provide such a service? (See Fact Sheet 1).

YES NO