Specialist team support vulnerable older people to return home from hospital
When older and more vulnerable people need a stay in hospital after illness or injury, helping them to return home afterwards can be complicated - often because their care needs at home can't be met straight away. For many people this means having to stay in a hospital bed for longer than is needed, which risks setting back their recovery.
A big part of the NHS's focus on moving more care from hospital into the community is to tackle problems like this, and NHFT's Dementia and Delirium at Home team is having particular success in this area.
Working closely with social care partners and with independent care providers, they support older people experiencing spells of sudden confusion (delirium) to return home quickly and safely.
The team is made up of nurses, occupational therapists and support workers who organise for patients meeting the right criteria to be transferred out of hospital to a nursing home.
Here they can get the care they need in a calmer environment, while the team makes a plan for their return home with 24-hour support from an independent home care provider.
Once they are well enough to leave, their nursing home place is kept open for 7 days, just in case they can't be supported safely at home. This reduces the risk of them having to go back to hospital.
They can receive care at home for up to 28 days, while social care teams arrange any longer-term care which may be needed.
This whole process is tailored to the individual's personal circumstances, with packages of support agreed with them and their families or carers.
In operation since January 2025, this care pathway has already helped 26 service users to regain their independence at home and plans are being developed to potentially expand it in the future.
Jenny Embling, Operations Manager for the Dementia and Delirium at Home team (pictured third left), said: "This care pathway is an excellent example of how joint working between the NHS, social care and independent providers can result in excellent outcomes for those we support.
"As well as supporting people to return home safely, the pathway is helping to free up hospital beds for those who need them - which is especially important during the winter when demand for hospital care is higher.
"By helping more people to get the care they need at home, our service helps to lower the demand for long-term nursing
home places too."