Hospital to Home

North East Hampshire and Farnham Clinical Commissioning Group has various services in place which aim to maximise patients’ independence following a hospital stay, aiming to support patients home as soon as appropriate and ensuring assessments are carried out in the right environment.

  1. Two processes based upon the use of well-developed assessment tools to measure the health needs of a patient, to facilitate the immediate procurement of services on a needs basis covering patients who suffer from delirium and people awaiting Continuing HealthCare assessments. The processes aim to minimise hospital dependency and cater for their specific requirements in the community. Depending on the patient’s condition this support is provided for between 28 to 60 days.

  2. Enhanced Recovery and Support at Home – provides a health and social care rapid response service with the objective of short-term rehabilitation support (used to be convalescence) in order to restore confidence and self-sufficiency.

  3. Hart Voluntary Action – has recently developed a service to include hospital discharge support for patients registered to a GP Practice in the North East Hampshire area. The service provides day to day emotional and practical support, including shopping, light household tasks and signposting and wellbeing calls, for some 6 weeks after discharge from Frimley Park Hospital along with Fleet and Farnham Community Hospitals. To this end three service coordinators are based in Frimley Park Hospital. Farnham patients can also access similar support, provided by Home Group.

  4. Two projects providing a total of 7 beds in North East Hampshire, offering interim placements in a supportive environment and an opportunity for rehabilitation and assessment away from the acute hospital. 2 beds support those with post hospital nursing needs, and 5 beds to support those with re-ablement/ rehabilitation needs. The objective is to assess capacity for rehabilitation and determine the longer-term need for support while in the community.

  5. A Project to support those who are candidates for returning to their homes with a form of live in care in order to build confidence and scope for independence following a stay in Frimley Park Hospital. The objective is to re-establish quality of life, maximise sense of independence and minimise the need to return to hospital.

The service selected for any one patient is based on their individual needs and is the subject of the consideration of a multi-disciplinary team such as the Integrated Care Team made up of colleagues from both the acute and community care teams.

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