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Northumbria Healthcare’s Hospital to Home team supporting patients to return home from hospital

Wednesday, 25 March, 2015
Northumbria Healthcare’s Hospital to Home team supporting patients to return home from hospital

A specialist health and social care team is working around the clock to support patients’ discharge from hospital in Northumberland and North Tyneside.

Northumbria Healthcare NHS Foundation Trust’s Hospital 2 Home (H2H) team is made up of multi-skilled health professionals including community nurses, social workers, occupational and physiotherapists, care managers, discharge nurses, support planners and care coordinators.

Timely discharge from hospital for patients was brought to the fore this winter with unprecedented demand on A&E departments and hospital beds across the country.

“We are one of the trailblazers for joined up care nationally and H2H is a good example of this,” said Jane Weatherstone, GP and clinical director for Northumbria Healthcare NHS Foundation Trust.

“It helps to get people through the system faster and more safely. The value of this joined up approach was demonstrated in winter during peak demand when the team worked at maximum capacity to get the right professional to the right patient and proactively get the patient home.”

Although a large proportion of the patients the team deals with are older frail patients, the team works in every speciality in the hospital.

Recent figures show the team supports an average of 350 people a month across Northumberland and North Tyneside.

Ms Weatherstone added: “The results have been impressive with increased patient satisfaction, more people maintaining their independence in the community than the national average, and fewer people requiring longer term support.”

Other initiatives in Northumberland include the Short Term Support Service, Immediate Response Team and the Joint Equipment and Loans Service.

Ms Weatherstone added: “There are real opportunities in having an integrated organisation which includes hospital, community health and social care services.

“Our philosophy is to join up social care with primary, community and secondary health care to provide a seamless service for patients.

“The services are responsive to each patient’s individual needs and are strengthening patients’ capabilities at home, which in turn are avoiding unnecessary hospital admissions, and supporting the earliest discharge from hospital as soon as hospital care is no longer needed.”

The Trust is in the unique position to be one of few in England to deliver adult social care in partnership with Northumberland County Council and it has been chosen to lead work with partners to deliver an integrated primary and acute care system (PACS) for the county. 

Work is now focused on reducing the number of people discharged from hospital into care homes and reducing the use of hospital care to support people with long-term conditions which will be part of the PACs.

The recognises the Trust’s work in bringing together GPs, hospitals, community teams and social care workers to jointly develop and redesign care and services to strengthen re-ablement and rehabilitation for patients.


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