Integrating community and voluntary sector knowledge and expertise into the discharge process

The Healthy and Home service launched in December 2021 at Warrington and Halton Hospitals NHS Trust, with the aim of helping to integrate community and voluntary sector knowledge and expertise into the discharge process.

The Healthy and Home service is delivered in partnership with Warrington Voluntary Action and is fully embedded within the Transfer of Care Hub, with two full time VCSE Link Workers liaising directly with the discharge team to make effective referrals into local community services for patients on a discharge pathway.

Help offered to patients can typically include things like:

• Providing practical support to facilitate rapid discharge such as welfare checks, essential food shopping, prescription collection, and access to mobility equipment, and further support for managing long-term conditions
• Coordinating specialist support from VCSE providers to support with housing, welfare, debt, benefits advice, support with food or fuel poverty issues, and carers support
• Providing ongoing community-based support for emotional wellbeing, such as befriending
• Coordinating follow-up calls or visits and assessment at home after discharge from hospital - 1 in 3 of all referrals have received additional ongoing welfare calls after discharge.

You can watch a short film which explains more about how the Healthy and Home model works, including a patient’s journey through the service, below.

Key benefits for the NHS workforce

• a single point of access for patient referrals
• a reduction in the time spent making patient referrals
• provision of a holistic assessment of individual patient needs
• access to a wide range of community-based support and information

Key system impacts

• Reduced length of hospital stay
• Reduction in delayed discharges due to wider VCSE support packages
• Reduced number of re-admissions for patients after discharge
• Reduced burden on out-patient services
• More patients going home rather than into other bed-based care facilities
• Improved health and wellbeing outcomes following a period of rehabilitation
• Reduced need for long-term care at the end of a person’s rehabilitation
• Patients empowered to regain or maximise their independence, to connect to their community, and enabled to continue to live at home.

Key patient outcomes

• In year one of operating, the team supported over 800 patients in Warrington and Halton, and in the first half of this year (up to June 2023), they have supported almost 800 again – which is a doubling of demand, which reflects how effective the initiative is proving
• Over two-thirds of patients who have been supported by the scheme haven’t gone back into hospital as a readmission, where they otherwise would have been more likely to.