Supporting patients following discharge and preventing readmissions

Mersey and West Lancashire Teaching Hospitals NHS Trust has developed an innovative Discharge Support Service, run by a committed team of volunteers. The aim of the scheme is to look at the impact on members of our elderly population after they return to their own home following discharge from our hospitals.

Volunteers contact the patient within 48 hours of being discharged to check on how they are and to see if they need any help or some interventional community support. As well as offering support for the patient, the scheme looks to prevent readmissions into hospitals when some patients find they are unable to cope when they first get home.

If, during the call, the volunteer identifies a patient who is struggling to cope, they will make referrals to local community services - Sefton CVS for Southport patients, and Age UK for West Lancashire patients.

These community services provide short term interventions and practical support that can include weekly visits, additional follow-up calls, referrals to shopping and cleaning services, advice on welfare rights, involvement with GPs, referrals to Occupational Therapy and to Social Services regarding packages of care.

This not only helps to prevent some readmissions, but also potentially allows the patient to stay in their home longer with additional support from the community.

Impact to date

An audit took place after the first 5,000 calls had been made and the scheme helped avoid more than 400 readmissions to hospital because of the early support offered, with patients benefiting from timely support such as:

• Regular welfare visits and telephone calls
• Initial shopping/food drop
• Referrals to Adult Social Care regarding self-neglect and safeguarding
• Referrals made to Fire and Rescue for free home safety assessment
• Contacts made with housing officers
• Referrals made for adaptations in houses