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Discharge to Assess helps 8,300 patients return home in first three years

Discharge to Assess helps 8 300 patients return home in first three years

Over 8,300 people have been helped to regain their independence at home following a stay in hospital thanks to Somerset’s Discharge to Assess service.

The service, which is funded jointly by Somerset NHS Foundation Trust and Somerset Council’s adult social care team, celebrates its third birthday this month – with colleagues and patients proud of its success.

It was initially formed from the NHS and council’s response to the COVID-19 pandemic – a time when it was vital to help people stay at home. It means patients can return home much quicker than before, reducing the need to wait in hospital for a long-term care package.

Clare Brolly, the operational flow manager at the Discharge to Assess team, explained how the service works.

“When a patient is admitted to one of our hospitals, they are assessed by a multidisciplinary team of health and social care professionals who will look at whether their care could be managed at home with a little extra support.

“We use a number of resources to support people to return home which may include therapy, reablement care, or equipment. As part of this, we work with patients in their home to carry out a holistic assessment, where we review their abilities and needs to understand how to help them to recover.

“We also provide a period of rehabilitation, centred around the person’s recovery goals, which helps to reduce the chance of them being re-admitted to hospital, or needing further care at our community hospitals.

“Many of our patients don’t need further support following care from our service, but for those who do, we help to identify the type of longer-term care that may be needed, or other support, such as from the voluntary sector.

“Colleagues in our Discharge to Assess team have learned so much in its first three years, we listen to our patients and colleagues about what works well and where we need to improve, and always strive to give the best service we can.”

Iona Brimson, strategic commissioning manager at Somerset Council, said:

“Our service is a unique collaboration of professionals across health, social care, home care reablement teams, night support, our community and voluntary sector, and unpaid carers.

“Going home and staying safe at home for as long as possible is so important to us all. We want people to leave hospital as soon as they become well and, for some people that may mean they need some extra help to get them confident and more independent.

“We have had some tough years with COVID and flu, and our joint partnerships have never been so important. Happy third birthday and a big well done to our strong workforce and Somerset community.”

“Being at home means everything to me”

Pat from Taunton was cared for by our Discharge to Assess team when she broke her wrist after falling over in her garden in 2021.

“The nurses and other colleagues were so caring, but I was glad when conversations started about leaving hospital,” said Pat.

“When I returned home, they helped me to become more confident on walking with the frame, and the team of reablement specialists who visited me, encouraged me to get out for a walk.

“I felt so reassured by the team and soon began to trust them, which is when the real progress of my recovery started.

“I’ve already begun taking gentle walks again, such as to the local church and back, and my ambition is to get back to walking my dog again.

“Every time I go out into my garden, I pick up a stone to add to my little Lent feature – I will have picked up 40 stones by the end of Lent, so I will have been out to the garden 40 times!

“I feel it would have taken me a lot longer to recover without the support of the Discharge to Assess team, and I wouldn’t have been sure whether I was doing the right things to make this happen without the specialist advice and support.

“The team helped me to live as normal life as possible in my own environment, and that was the most important thing to me. Being at home means everything to me.”

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