Supporting hospital patients to return home earlier and to live independently

Evolving Communities worked with Wiltshire Council and Wiltshire NHS CCG to evaluate the effectiveness of Home First, a new initiative that aimed to facilitate early discharge of patients aged 65+. We worked with the client to hold focus groups, attended meetings and gathered feedback from patients, relatives, staff and other stakeholders.

Better Care Fund

The Better Care Fund is a programme spanning the NHS and local government.  It seeks to join-up health and care services, so that people are better able to manage their own health and wellbeing and live independently in their communities for as long as possible.

Delayed Transfers of Care

One of the areas where the Better Care Fund is typically used is to provide initiatives that aim to reduce the numbers of delayed transfers of care (DTOC).  Transferring medically fit patients out of inpatient care to their own home in a timely fashion can be challenging to the healthcare system.  Although deemed medically fit by the medical team, older patients may continue to have mobility issues, social issues and may also still require assistance with the activities of daily living.  Despite this, they do not need, and often do not wish to remain in an acute hospital bed.

Home First initiative

Wiltshire Council and Wiltshire NHS CCG are committed to reducing the number of delayed transfers of care.  They also saw the benefit of helping people to become as independent as possible, thereby decreasing the intensity of their ongoing package of care.

They were supported by the Better Care Fund to establish Home First – a new initiative that aimed to facilitate the early discharge of medically fit patients aged over 65 to their own home.  Rehabilitation workers and therapists were employed to support people for up to 10 days after discharge from hospital.  Patients were able to come home earlier while still receiving care and support, and this also allowed more time for longer-term packages of care to be put in place.

Our work

We evaluated the effectiveness of the Home First service from the point of view of patients, relatives, staff, and stakeholders.  Over a four-month period, we gathered and analysed people’s experiences and views of using or providing the service.

We held focus groups, attended multi-disciplinary team meetings, visited local support groups, conducted one-to-one interviews, and ran an online survey, giving all of those who took part many ways to engage with the evaluation.  Our report presented findings and made evidence-based recommendations.  System leaders valued the deeper insight into the initiative and made plans to incorporate our recommendations into future development plans.