In October 2004 Willow Housing and Care, a sheltered housing provider, set up a support service in Brent to help older people return to independent living more quickly following a stay in hospital. Now in its sixth year, the service is producing real success stories.
Supporting older people leaving hospital
An older person may face a number of challenges when they return home after a stay in hospital.
“It might be that their home is no longer suitable because they physically can’t manage unless aids and adaptations are fitted,” says Mary Whitfield, Willow’s Director of Supported Housing. “Utility bills may not have been paid while the older person is in hospital and contact needs to be made with the utility companies. Or advice is needed on future housing options for the older person. Their accommodation may need cleaning or the bedroom moved downstairs so they can they stay independent”.
In 2004, Willow Housing and Care, a specialist provider of housing and support services for older people, identified a lack of support and guidance for older people readjusting to their lives after a stay in hospital. This increased the likelihood of hospital re-admittance or an unnecessary move into residential care after an older people remains in hospital longer than necessary and becomes dependent.
Willow approached Brent Council’s Supporting People commissioning team and offered to set up a new service to support older people leaving hospital, and help them return to independent living – the Hospital Discharge and Prevention Service.
Initially Brent Council agreed to fund one support worker to deliver the service as a pilot. They have reviewed the funding annually, and there are now two full-time workers and one part-time worker, as well as an additional part-time support worker in Harrow. Each has a caseload of 25 people.
Bespoke support for the individual
Willow’s approach is to hold discussions with the older person, their relatives and health and social care staff. This way, the support worker can find out the person’s requirements and aspirations and develop a support plan tailored to their specific needs.
As people are referred to the service while they are still in hospital, this approach means that support workers can make sure that everything is in place when the person is ready to go home.
Housing support is usually a key feature of any such plan. Support workers will do joint assessments of the person’s home and ensure any recommended adaptations take place, such as installing a fall detection system, fitting grab rails or a community alarm.
“We would look at grants for insulation to keep them warm or aids and adaptations to help them stay in their home and remain independent,” Mary says.
If the person is living in poor quality housing or being threatened with eviction, then it may be necessary to assist them in moving to an alternative home of their choice, the service enables older people to make informed decisions about their housing.
“If they are saying they want to stay in their home, then we do our best to help them stay in the property they are in. If that’s not possible or they don’t want to, we will help them look for something more suitable,” Mary says.
The support plan also takes into account an individual’s wider housing related needs. For example, if someone has fallen behind with their bills, support workers give advice on maximising income and managing budgets.
Staff take a multi-agency approach in providing full support to client that enable them to live independently for as long as possible.
More than a ‘signposting’ service
As well as offering one to one housing related support, the service acts as a point of contact to help people access a wider range of support services. Whatever the needs of the person, support workers are there to support them as much as they want.
Workers can make referrals to the social care service if somebody needs care at home, or to the pension service if somebody’s benefits and allowances need to be reviewed. They can help older people access GPs or refer them to specialist charities such as Age Concern or Macmillan Cancer Support. They can also send reminders to attend GP appointments or assist in filling in benefit applications.
If a person is feeling socially isolated, workers can provide information on local events and activities to help them make links within the community.
“Some people may feel isolated because they haven’t made links in their local community and we can help them to make those links. If there are any community groups they want to go to we will arrange for this happen and if need be go with them on their first visit. . If language is an issue, we can use interpreters” Mary says.
Local services working together
Mary stresses the service is built on partnership working.
“It wouldn’t work without support from [Brent] Adult Social Services and the hospital teams.”
Because everyone sees the benefits of the service, there are now regular hospital discharge meetings between Willow, Brent Social Services and the local hospital to discuss patients.
“The fact that the hospital invites a housing professional to attend [the hospital discharge meeting], that’s a move forward. It used to be hard to get health and housing professionals to meet together” says Mary.
“The real contact is staff on the ground who are doing the job. They have really good working relationships and that’s why it works.”
Willow support workers are also co-located with social services staff, which helps build relationships. Hospital staff are able to call Willow workers directly to refer new patients who they think may need some support.
“Because they work so closely together, the hospital might ring up one of the workers or social services and say they have someone who has come in and needs support now so they can start the process immediately,” says Mary.
Success stories
Support workers generally work with a person for approximately six months, although it will depend on the needs of the person.
At the end of the service, people are asked for their views. Comments are generally very positive.
“The support worker was very helpful and friendly. She helped me to apply for housing as I was in a hostel. I now feel independent, confident and in control of my life. Also, I have had equipment fitted which will prevent me from falling” said an older person who recently left the scheme.
There is evidence that the service has enabled people to remain independent for longer. Analysis carried out by the Department of Health’s Care Services Efficiency Delivery Programmes showed that, in a sample of 20 people who used the service, 65% were able to return to independent living rather than move to a more intensive setting such as a care home. The service was short-listed for the Guardian Public Service Awards 2009.