Supporting older people after discharge

Meeting the needs of vulnerable older people is a complex matter that demands a high level of planning, co-ordination and expertise. With older people, particularly those who have had a stay in hospital and who fall under the responsibility of different agencies at different times, a joined-up approach to delivering the best outcomes for all parties has proved to be very effective.

Delayed discharges are not in the best interests of the patient and can also lead to fines being levied on local authorities as beds are not freed up for new patients. However, with a co-ordinated approach and forward planning this situation can be avoided, leading to better outcomes for all involved.

This has been the case in theLondonborough of Brent where, for the past two years, a scheme has been in place to co-ordinate the discharge and accommodation of vulnerable older people from hospital. In all, more than 150 people have benefited so far from the housing/hospital link scheme that Willow Housing and Care developed and a significant amount of money has been saved by social services in bed blocking fines.

Patients are enabled to leave hospital in a planned way, to suitable accommodation and with an individual support plan in place which is based on meeting that person's needs and aspirations. The support plan is a tool to co-ordinate the input of agencies to enable the older person to remain living independently in the community and reduce the number of readmissions to hospital.

A floating support service is operated by London-based Willow Housing and Care, and is led by a manager with a team of five staff. Funded through Brent and Harrow Council's Supporting People programmes, the floating service focuses on the housing, social and support needs of each client. This helps prevent loneliness and inactivity, which can lead to deteriorating health, and enables each individual to maximise their independence within the community.

Each individual referred to the servicehas a one-to-one meeting with a support worker to discuss their needs and aspirations. The support worker outlines and advises on options for housing and related support services and the client is encouraged to identify what they would like to achieve. This forms the basis of an individually tailored support package that reflects and respects the choices of the service user.

The servicealso liaises with statutory agencies and local voluntary organisations such as Elders' Voice, which runs day centres, a handyperson service, and Time of Your Life, a multicultural befriending scheme, to provide services that complement those provided byWillow'sfloating support team.

The success of the housing/hospital link worker and floating support services is based on co-operation and partnership working to achieve shared goals. The numbers of older people remaining in hospital after treatment when they are ready to be discharged has been reduced. Many others have been enabled to remain living independently and actively in their own home rather than moving into residential care. Investing in these innovative approaches to meeting the needs of an ageing population has fostered joint working towards common goals, making best use of finite resources to improve the quality of life of some of our most vulnerable members of society.