Home from Hospital Service

Health Care & Well-being Forum

11th December 2014Suzanne Hilton

Chief Executive

Age UK Bolton

The Challenge• Older people rely

more on GP & acute services

• Two thirds of people admitted to hospital are 65 plus

• Older people stay longer once admitted

• 80% of delayed transfers are over 70

• In last 10years re-admissions risen 88%

• Re-admissions in 30days cost NHS £2.2bn

The Bolton Context47,000 over 65s

37% live alone

Almost 50% of over 75s live alone

14% of over 65s care for another

12% more deaths in winter-27,000p.a. 206 everyday

Estimate 3,700 over 65s will be discharged over the winter months

October 13 to March 14 9.4k attendances at A&E by over 65s- mild winter

Epidemic of Loneliness

• Loneliness linked to poor health, morbidity & depression- Worse than smoking 15 cigarettes a day

• People who regularly experience loneliness are 2 x more likely to develop Alzheimers

• 25% of people 52+ feel lonely sometimes or often

• At 80+ nearly half feel lonely often

• 1 million people over 65 feel lonely all the time

• Families at a distance (where children live more than 1 hour’s drive away 50% older people see them only every 2-6months)

AUKB Home from Hospital

Short Term/Time Limited Medium Term/On-going

Presence in A&E and on wards Befriending Service and afternoon teas to tackle loneliness & isolation

Early discharge planning and full assessment before deflection or discharge from hospital

Medication & appointment reminders

Involvement with MDTs Lunch & Leisure Clubs- hot meals in a social setting

Getting home safely- opening up, putting the heat on, organising aids & adaptations prior to arrival

Support at follow-up medical appointments

Immediate practical support- collecting prescriptions, organising meals delivery, washing- up, help to deal with correspondence built up whilst in hospital etc.

One to One support and encouragement to work on rehabilitation goals identified by healthcare professionals. Plus support to regain confidence in daily independent living tasks

AUKB Home from Hospital

Short Term/Time Limited Medium Term/On-going

Home checks-falls prevention, fire safety Chair-based exercise to promote steadiness, mobility and independence

Follow-up calls and visits for emotional and practical support

Falls prevention checks

Information & Advice e.g. help with benefit applications for help with the cost of additional support

Handyman service for help with gardening and DIY to manage the home

Signposting to other services, GPs, Careline, Care & Repair, Single Point of Access

Hobby and creative activities and digital inclusion support to stay connected with family and friends at a distance

Liaison with family, friends & neighbours Befriending support to tackle loneliness and isolation

Medication & appointment reminders

Reduction in unnecessary hospital re-admissions & crisis care

interventions

Age UK Tried and Tested Model

The EvidenceSheffield Hallam evaluation of Age UK Rotherham scheme and PSSRU other Age UK services including Stockport & Salford in GM:

R.o.I.- Between £1.50 and £6.30 for every £1 invested in H.f.H schemes

Reduced avoidable re-admissions an crisis social care interventions

Reduced hospital stays, A&E visits & hospital based physio’ by up to 50%

Further 15% reduction in GP appointments

Rotherham saved £74k p.a. in bed days, additional up to £18k p.a. for hospital transport and forecast £358k-£717k across health & social care services in 12months.

Partners & FundingPartners

Age UK Bolton- lead delivery partner & funder

working with Senior Solutions

Bolton FT Hospital – host & in-kind support

Funding

CCG -£55k (£30 AUKB + £25k SS)

AUKB - £30k

BMBC - £30K

Outcome Measure

Reduced emergency and avoidable (re)admissions

% of older people supported by HfH readmitted as inpatients or attending A&E compared to % of wider 65+ cohort

Reduced & delayed admissions to residential care

Recorded number of 65+ still at home 30 days after discharge

Improved experience of care for older people and their carers

Evaluation feedback questionnaires from HfH clients

Increased number of older people who feel supported to manage their own health and long term conditions

HfH clients still at home 30 days after dischargeEvaluation of feedback questionnaires on personal recovery goals

Increased satisfaction with care & support provided to older people

Evaluation feedback questionnaires from HfH clients

Going Live

• Staff team recruited

• Building volunteer team- ahead of profile

• Setting up base in the hospital

• Aligned to Staying Well

• Developing data capture, referral mechanisms and monitoring and evaluation systems

• Launches on 15th December

Loving Later Life

suzannehilton@ageukbolton.org.uk 01204 701525 / 07790 817454