Delayed discharge: how Willow Housing and Care links health and social services

A hospital visit for an older person often results in a stay which is far longer than necessary, causing problems for the health service, social services and, most importantly, patients and their families. But the floating support service set up by Willow Housing and Care, a housing association in Wembley, London, aims to transform the system.

The service promotes the timely discharge of older patients from hospital, improves joint working between housing, health and social services and provides support and advice to patients as they move from their hospital bed to the right home environment.

It helps those who are ready to leave hospital but cannot return home immediately, perhaps because their home needs to be adapted or they need alternative housing, with a higher level of care.

Willow Housing and Care, set up the service to help local people retain their independence for as long as possible. Its chief executive, Judy Peaker, says support and advice for patients and their families is essential, both while they are in hospital and afterwards.

“As well as helping people leave hospital when they are ready to do so and moving them into the most appropriate accommodation, we work with other agencies to provide care for up to six months, whether this is at home, in extra care or in sheltered care housing,” she says.

Retain independence

Peaker highlights the problems that can be faced by older people leaving hospital, such as a risk of falling, feeling isolated, needing help coming to terms with bereavement or help and advice in other areas.

Mercel Hislop, who leads the support service’s team of five, says: “We work with older patients in hospital and their families to make sure the support is in place so an elderly relative can retain their independence on leaving hospital.”

The team’s responsibilities also include providing advice about claiming benefits, says Hislop, as well as a range of other work. This includes helping people move home, going with them to view possible accommodation and arranging removals. It might also include making sure they are registered with a GP, dealing with utility bills and other paperwork and working with social services to carry out a community care assessment.

The range and complexity of problems faced by older people leaving hospital is often exacerbated by a lack of joined-up thinking and competing funding streams from the different organisations involved in providing health and care services. Essentially, this means organisations passing the buck, which can result in lengthy delays to patients receiving the right care.

The floating support service overcomes this by having a single pot of funding from the government’s Supporting People programme, which backs housing-related schemes that aim to help people live more independently.

This focused approach has several ­benefits, not least reducing the level of delayed discharge payments levied on councils by hospital trusts and primary care trusts. The service also has obvious benefits for the health service, freeing much-needed beds and helping to ensure older people are less likely to return to hospital.

Helping people live independently or in sheltered or “extra care” housing also relieves pressure on residential care and meets the government’s goal of fewer people living in traditional care homes.

New friends

Most importantly, the service, which began in Brent but now covers neighbouring Harrow, is a hit with older people.

Victor Tinkler was one of the first of more than 100 people who have benefited from the service when he moved to a ­housing scheme in Willesden after a stay in hospital. He says he felt some trepidation at first, but adds: “I have made a lot of new friends here. We meet every Thursday for a coffee morning and on a Friday for fish and chips. We have even been on a day trip to Southend.”

The service encourages residents to become involved in social and recreational activities after leaving hospital, as well as working with them and their families to ensure they play an active part in decisions made about their future health and care needs.

The team works closely with patients to ensure they receive the right care, representing older people when it comes to dealing with often complex housing issues and providing ongoing support.

All of which means that the prospects for older people in this part of north west London leading a fuller life after hospital discharge are much improved.

For more information call Willow Housing and Care on 0800 169 3508

This article appeared in the 14 February issue under the headline “Seamless support”