Discharge orders

Hospital discharge service in Teesside delivers dramatic improvements to patient outcomes

From being kept on a hospital ward for 144 days to now living freely in the community managing their own tenancy, a hospital discharge service in Teesside has made significant improvements to patients’ lives.

Working with Tees, Esk and Wear Valley NHS Foundation Trust, Home Group introduced a dedicated Hospital Discharge Service (HDS) to the hospital to help reduce the length of stay on hospital wards and support an effective route to discharge into the community.

Once established, the HDS team form part of the customer’s discharge planning team, alongside the NHS provider, and help to develop a person-centred plan in order to provide a timely discharge into the community. They will provide housing support to patients ready for discharge into the community through three main methods: advocacy and advice, practical support, and emotional support.

This includes a wide range of assistive services aimed at ensuring the most suitable discharge from hospital as possible, from signposting relevant services and supporting with filling in any required paperwork through to developing essential domestic or life skills.

In one case, the HDS team worked with Tees, Esk and Wear Valley NHS FT to support a patient with complex needs to be safely discharged from a hospital setting into his own property in the community.

Customer C, a 24-year-old male in Teesside, has a learning disability, autism, DiGeorge syndrome, anxiety and OCD and had been living in temporary accommodation prior to his time in hospital, following a significant deterioration in his mental health.

In total, Customer C spent 144 days on a ward, between Roseberry Park and Lustrum Vale hospitals, before deciding he was well enough to leave.

In anticipation of a discharge, Lustrum Vale hospital colleagues involved the HDS team, who became involved in April 2021. By mid-September 2021, the customer was able to be discharged from the ward into a supported housing scheme in the community.

Since his discharge from hospital, Customer C has been described as being positive with regards to his future now he has his own tenancy and safe accommodation. He remains compliant with medication and engages with the support offered through his tenancy.

Being able to use housing expertise, the HDS team was able to reduce delays in finding an appropriate tenancy, support the customer through the process, and relieve non-healthcare tasks and questions from the Tees, Esk and Wear Valley NHS FT staff.

Staff at Tees, Esk and Wear Valley NHS FT have described the service as being able to lift this burden from ward staff, while still ensuring close collaborative working and keeping the patient’s needs front and centre.

One NHS staff member described in a 2022 feedback session: “[Home Group] massively helps with our role as a Care Co-ordinator with a large caseload. We do not have the dedicated time we would like to focus on peoples housing needs, so they have been a great help with this.”

Another described the service as a “valuable asset” which has been able to help even the most complex needs.

They wrote: “They have shown they will go above and beyond to help the service users that I have asked them to work with. They have provided informative advice and signposting and not excluded anyone and even when the service users have been really challenging and have complex needs, they have given it a go.

“They have been a valuable asset to the team, and I hope they can stay with us as a permanent fixture.”

Asked to score the service across four questions on a scale of 1-10 (with 10 representing the best), the HDS team were graded against the quality of support, communication, meeting objectives, and helping staff in their own roles. The services scored an average across the four questions of 9.83.

A study of Home Group’s two active North East-based hospital discharge services, which compared the duration of inpatient stay for individuals with a housing need prior to the service being introduced and once it was live, showed there was a reduction in the average length of a ward-based stay of 71 days per person.

This equated to a saving per person of over £27,000, or a total of £1.5m across the 56 service users involved in the study.

For more information on Home Group’s Hospital Discharge service or any of our other New Models of Care services email [email protected]

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