Early successes for new hospital initiative

Whilst still in an early phase, staff working on a new initiative to support people in getting home from hospital are seeing some real positive successes


After being selected as one of the first sites in the UK to transform the way health and social care is provided under the NHS England Vanguard scheme, Stockport has been working on a number of initiatives to improve patient experience.

A team working on the Short Stay Older Peoples ward at Stepping Hill have been working with patients to ensure that they are able to safely return home as soon as they no longer require acute services.

One such patient who has benefited from the new service, is 99 year old Esther. The new way of working stopped her needing to be admitted to a residential care home, which may have been the expected route after a stay in hospital. The team were able to assess Esther’s requirements whilst she was still on the ward and help her to make a speedy recovery and get her back home to carry on her recuperation.

It is widely acknowledged that people are likely to recover much more effectively in their normal home environment once it has been identified that they no longer need clinical support delivered in a hospital setting.

This new way of working, which has been introduced as part of Stockport Together, has introduced an assessment process which the teams follow to ensure that all the appropriate services are in place for when a person is discharged back to their home setting after a stay in hospital.

Jaweeda Idoo, GP at Stockport’s Alvanley Family Practice and Interim Clinical Director for Stockport Together, explained: “When someone is admitted to hospital, staff carry out an initial assessment of that person, and identify an anticipated date of discharge. This then provides a date that the teams can work towards so that they know when any services that will help a person’s recovery need to be in place.

“In Esther’s case, the team was able to assess her care package needs whilst still in hospital. They then made a visit to her home to work out if any modifications or additions were required to make her home safe for her return.”

Getting the services lined up is a real multi-disciplinary team effort, with the consultants working with ward staff and therapists to complete a ‘Rapid Assessment’ tool. They then work with the ward pharmacists to ensure the person has the correct medication. The pharmacists’ works directly with the patients to ensure they understand what has been prescribed and how to self-medicate when they get home.

Once all of the activity within the hospital has been carried out and the person has been discharged, a member of the Active Recovery team will carry out an assessment in their normal environment which is the best way to understand their needs. This helps to ensure that the person has all they need to recuperate and can focus on maintaining their own independence.

This work is helping to reduce the length of hospital stay for patients, and by completing a full assessment of a persons’ needs in their home environment, it is also reducing the risk of readmission.

In order to ensure that people are aware of the new process, a patient information leaflet has been created in conjunction with Healthwatch. This is given to people and their families or friends as soon as they’re admitted to help them to understand the reasons why it’s safer and more effective to recover at home.

Plans to roll out to other wards will commence from April.

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