Katie is one of a handful of social workers in Somerset supporting a service that helps people who need support settle into home life after a spell in hospital. The support is called the health interface service (HIS) and is how Somerset County Council delivers its promise to promote independence for its residents who have experienced some sort of destabilised episode such as a fall or stroke.
“As an older person when you are in hospital, there is a risk that you can lose muscle tone and independence, so HIS is designed to support people’s move back into their homes as soon as possible,” says HIS strategic manager Lynn Stephens.
For Katie, the role is appealing because, although she typically has an average caseload of about 20, she never holds on to a case for long periods of time.
“She gets involved quickly with people at crucial times in their life and this can make a real difference to whether they can go back home to live independently surrounded by their friends, family and all that is familiar to them,” says Lynn. “Turnaround times can be between three and six weeks and there’s quite a lot of throughput,” says Katie. “So, you’ve got to be able to pick cases up quickly and that is one of the values of the service.”
Tailored model
Katie works closely with occupational therapists, nurses, colleagues in the voluntary sector and care providers to develop bespoke support plans for people to help them at home. She liaises with the team and reviews this regularly. This is all part of the adopted discharge model across the hospitals in Somerset known as Home First.
According to Lynn, at the end of August 2019, Somerset’s beds figure for delayed transfer of care (DToC) (which is calculated as the average number of delayed transfers per day pro-rated for population) was 7.7. The equivalent figure for England was 10.2 and for the South West it was 12.8.
The next stage is to deliver a seven-day service so that people are not disadvantaged over the weekend and in the evenings. Staff will have some flexibility over hours if rotas are covered and there will be an enhanced level of pay for out of hours working. “We have found that some people like working in the evenings because it allows them to develop an holistic approach to the care they offer. They are able to meet the families of the people they are supporting and that gives them a fuller picture of the person’s home situation,” says Lynn.
Multi-agency partnerships
Katie’s role includes collaborating with other agencies to provide additional community support to adults coming out of hospital. Social workers liaise with the NHS and third sector organisations such as the Community Council for Somerset and British Red Cross, to provide additional community support to adults coming out of hospital.
This multi-agency approach allows social workers to inject some creativity into the care packages they create for the vulnerable adults they support.
“The whole programme is about linking people into their communities and in doing so, creating stronger communities,” says Lynn. “We are looking at promoting independence through something we call community connect. So, if a vulnerable adult was a keen gardener before hospitalisation, we look for ways to ensure that that kind of pastime can be incorporated into the support we also offer. We have found that this approach helps people to integrate much quicker back into their community and aids in their rehabilitation process.”
Strong communities
“Somerset is good at that because we already have some strong communities and lots of ongoing work,” says Lynn. “And we have people called community agents that work in communities and try to identify or grow the sort of support communities are best placed to provide. We also have a community agents based in our acute trusts to assist with plans after discharge.
Somerset also benefits from having a network of micro-providers that help to connect populations in rural parts of the country and to provide o essential social care.
“Somerset is made up of lots of small rural villages so it can be hard for social workers to travel around,” says Lynn. “Having micro-providers that provide care in each village is a good resource for social workers and makes it a lot easier for people to access the help they need.”
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