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Hospital to Home Team

Date issued: June 2022

Review date: June 2024 

Ref: D-377

PDF:  Hospital to Home Team final June 2022.pdf [pdf] 63KB

How long does the service last?

The Hospital to Home Team is designed to support you for a short time on your discharge from hospital. We aim to have completed your rehabilitation in 7-14 days.

How much does the service cost?

The Hospital to Home Team is funded by University Hospitals Plymouth NHS Trust and is a free service.

If you feel you need further support after this period, you will be referred to Adult Social Care and this may involve a cost and financial assessment however Adult Social Care will explain this to you.

Can I refuse this service?

Yes, if you are able to make an informed decision around your discharge from Hospital you are able to decline being discharged home via Hospital to Home.

However, we would recommend individuals and/or families discuss this with staff on the ward initially, or where appropriate the Integrated Hospital Discharge Team (IHDT).

What is the Hospital to Home Team?

This is a new team created by University Hospitals Plymouth NHS Trust with the aim to offer a short period of rehabilitation, in your own home, after your discharge from hospital with the aim to eliminate the need to wait for a Community Hospital or wait for a short-term package of care.

We appreciate that returning home after a period of illness can be daunting and are here to support you alongside voluntary organisations such as The Red Cross (registered charity).

Who is the Hospital to Home Team?

We are a team of Therapy Support Workers (TSW) lead by an Occupational Therapist (OT) and a Physiotherapist. We are part of the IHDT (Integrated Hospital Discharge Team) and supported by Nurses, co-ordinators, and admin to provide a successful service.

How does the service work?

We suggest that either your family or the Red Cross take you home and settle you in. The Red Cross can assist you with shopping and making sure you have the essentials for returning home.

Later that day you will be visited by an Advanced Therapy Care Support Worker or Qualified OT or Physiotherapist who will complete your initial assessment.

The initial assessment will consist of:

Home Environment Review, we will assess potential areas of risk within your home and make recommendations to improve this with some suggestions of equipment, if required.

Mobility Review, we will check your mobility around the home, offer suggestions for alternative equipment, check your existing equipment and replace if necessary.

Therapy Goals, we will check you have your home exercise plan and are happy with the exercises given to you.

Also, we will review your perceived needs and ensure you know when your next visit will be. This will be recorded on care plans and you will be left with a copy of your paperwork for your reference.

You will then be visited by the Hospital to Home Team as agreed to practise your exercises and the pre-agreed tasks e.g., washing and dressing or meal preparation, with the hope you start to grow in confidence and become more independent and no longer require support.

Why am I being offered this service?

The Hospital have completed your treatment and believe you are medically stable and well enough to return home.

You have been assessed by the multi-disciplinary (MDT) team at the Hospital as requiring a small amount of temporary support/daily rehabilitation at home when you are discharged from Hospital.

What are the benefits to me?

The Hospital to Home Team offers you the opportunity to have daily therapeutic support in your own home. After a stay in hospital, you may be anxious about returning home or fearful of falling.

We will assess you in your own environment to offer support and advice to reduce the risk of falling, performing activities of daily living and improve your muscle strength. All these factors will aim to maximise your independence in a short period of time and aim to avoid needing a longer-term package of care whilst preventing the need to stay in hospital for further rehabilitation.

We also hope that the period of rehabilitation will improve your quality of life and reduce the risk of further admissions to hospital.

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