A trial scheme offering at-home support to people who may end up in hospital is under way in Portsmouth. It aims to provide support to those in need in their own homes. Health reporter Priya Mistry finds out more.
A simple task like making someone a cup of tea, ensuring their heating is working or that they have lunch could mean they avoid having to stay in hospital.
This sort of care, as well as more complex checks such as blood pressure, medicine dosage and helping people to stay mobile is making the difference so some patients can live independently in their homes instead of taking up a bed in Queen Alexandra Hospital, Cosham.
The Enhanced Recovery and Support at Home (ERS) is a trial scheme being jointly run by Southern Health NHS Trust and Hampshire County Council.
The £700,000 project started in October and helps frail, elderly people – who have been in hospital frequently – to have support in their own home.
Since it was launched the service has helped 139 patients – and of those only five have had to go back into hospital.
Angela Wilson is the team leader for the service and says: ‘Of course hospital care is needed and we aren’t trying to replace that.
‘With older people and those with multiple health problems, they sometimes need help to get readjusted back at home, they need guidance, and that’s where we come in.
‘For instance, someone may have had physiotherapy work in hospital with stairs, but this can be very different to a person’s stairwell at home.
‘So if a patient is referred to us and they have mobility problems, then we might send out a physiotherapist to help them be mobile around the house.
‘Often in a hospital people will say they are fine, or they can walk okay because they want to get back.
‘But when they do get back they find they can’t move about like they used to and that’s when the problems can get worse. So we do stair work in their home and help them get mobile again. At the same time we will see if they need any equipment and ensure they are doing well.’
The team mainly gets its referrals from the accident and emergency department in QA to avoid them being readmitted.
Staff in the ERS work on three main principles – recovery, reablement and rehabilitation.
With this in mind the aim is to prevent people becoming so ill that they need another stay in hospital.
Angela adds: ‘For the first time we are linking everything together and putting the patient in the middle.
‘We are working with mental health specialists as three-quarters of the patients we see have some form of dementia and that can add to their problem.
‘We work with social services, so if someone isn’t getting enough food then they can have Meals on Wheels, or if a carer needs respite help then this is given.
‘Rather than waiting for a person to get so ill that they need hospital care again, we support and educate people in their homes to help them stay independent, get better and hopefully keep them out of hospital.
‘Something simple like making a cup of tea, making sure the heating is on and working, or making sure meals are ready can help people in such a big way.
‘Keeping warm means you are less likely to get hypothermia, so something like turning up the thermostat could prevent a hospital stay.
‘If someone has a messy kitchen and dirty dishes, then we will clean up as that could prevent poisoning of a patient and again keep them out of the hospital.
‘We check the home to make sure there are no obstructions and people are mobile so they do not fall over – we really aim to put the patient at the centre of our work.’
It’s something elderly couple Joan and John Holmes have had experience of.
Mr Holmes, 86, has been in and out of hospital after suffering a number of urinary tract infections and also fell over, cracking his vertebrae.
After being admitted in December again, the retired bank area director was referred to the ERS team, which covers Gosport, Fareham, Havant and Waterlooville.
Even though he was discharged on Christmas Eve, members of the ERS visited Mr Holmes in his home in Milton Grove, Locks Heath, to assess him and see what help he and his wife would need.
Josh Hammond is an assistant associate practitioner for the ERS, which means he can perform more duties than a nurse.
He says: ‘A lot of the work we do is confidence-building and ensuring people are comfortable.
‘With Mr Holmes we helped him get up and down the stairs, and initially helped to dress and bathe him.’
Mrs Holmes, 78, says: ‘Without a doubt this team is wonderful, they are all so great and have really helped us out.
‘They have helped with his mobility and initially with things like bathing and having a shave.
‘He can be stubborn at times, but when the team come over they know exactly how to help him.
‘They have such a difficult job but each time they come over they make you feel like you’re the only person they see.’
And Mr Holmes also appreciates the help he is getting.
He says: ‘I’m always pleased to see them, they are friendly, lovely people, and they always discuss things with you. They are very good at helping you out.’
The service is due to end in March, but the team hopes funding will continue so it can carry on.
Steve Taylor, manager of patient watchdog group Hampshire Healthwatch, says: ‘It’s very positive, we need more of this type of thing and we support it.
‘The more organisations we can get working together, then the better it is for patients, which is the key to this. We need more schemes like this as patients can be cared for the best, most of the time in the community, like their home.
‘Patients tell us often they want to be supported at home and the healthier lifestyle will be better, so it’s good to see this.
‘It also frees up beds in hospital to treat those patients who most need acute care.’
Making a difference
AFTER just one week of help from the Enhanced Recovery and Support at Home team, this pensioner was out shopping on her own.
Victoria Ryan, 89, was admitted to Queen Alexandra Hospital last month after having stomach problems and then again because of an angina attack.
She was discharged on December 23, and Josh Hammond explains what happened next.
He says: ‘When Victoria was discharged we would visit her twice a day and we realised we needed to help build her confidence up again after her stays in hospital.
‘So we started to support her mobility and work with her to get her around the house.
‘We also noticed she wasn’t eating a lot, so we would make up her lunch for her and make sure her heating was on so she wasn’t feeling cold.
‘We carry on with our welfare checks to ensure Victoria is doing well, and we check her blood pressure and whether she’s got the right medication, so she’s on the right path.’
Helping Victoria, a retired cleaner for the former Royal Haslar Hospital in Gosport, worked as she built up the confidence to go food shopping alone.
She was able to get a taxi to the Morrisons store in Gosport, have an shop assistant help her, and then come back home again.
She says: ‘This team is wonderful, they are so good to me and I cannot say enough how much they look after me.
‘They visit and check things are okay and I like having them.
‘I have had two heart attacks and a stroke, I can’t see out of one eye or hear from one of my ears – I’m very old.
‘But these people are excellent at helping to take care of me.’
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