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Resource Topic: Reablement & physio

Supporting Safe Discharge and Continuity of Care at Imperial College Healthcare NHS Trust

Background

As part of its commitment to improving patient flow and ensuring safe discharge from hospital, Imperial College Healthcare NHS Trust partnered with HomeLink Healthcare to address challenges in managing patients requiring complex wound therapies outside the hospital setting.

The collaboration began at St Mary’s Hospital in Paddington, where surgical teams were experiencing delays in discharging patients following vascular procedures. Many patients required Negative Pressure Wound Therapy (NPWT) for wound management after surgery, which created logistical and operational barriers to discharge. Variations in community services across London boroughs meant that consistent support was not always available.

The Challenge

The vascular surgery team faced a recurring issue: patients requiring NPWT were often unable to leave the hospital because of limited availability of pumps. In several cases, pumps provided to community services were not consistently returned to the Trust, creating shortages on the wards.

As a result:

  • Patients medically ready for discharge remained in hospital beds.
  • Delays impacted patient flow and surgical capacity.
  • Patients living alone faced additional challenges managing wound therapy at home.

The HomeLink Healthcare Solution

HomeLink Healthcare was initially commissioned to provide a bridging service for patients requiring NPWT after discharge.

Under the initial contract:

  • Pumps were provided under a contracted arrangement with HomeLink Healthcare, ensuring continuity of NPWT after patient discharge.
  • Clinical support was provided by HomeLink Healthcare in the community, allowing treatment to continue safely at home.
  • Assisted patients living alone who required additional support to manage therapy.

This approach allowed the team to trial the service over an initial six-month period.

When required, some patients were transported home by electric taxi with a HomeLink nurse accompanying them to facilitate safe discharge.

The early success of the programme led to the development of a formal business case to reinstate and expand the service.

Service Expansion

Following the positive outcomes from the vascular surgery pathway, the partnership evolved.

HomeLink Healthcare’s services expanded into additional clinical areas, including Orthopaedic services, supporting post-operative patients and therapy pathways and Medical support, particularly through support for Outpatient Parenteral Antimicrobial Therapy (OPAT), enabling patients to receive IV antibiotic therapy at home.

In addition, HomeLink Healthcare delivered a comprehensive physiotherapy provision to ensure patients remained safe and supported at home following discharge from hospital. This included both same-day therapy assessments for patients requiring immediate input, as well as short-term rehabilitation support for those facing delays in accessing community services. In many cases, where waits for community therapy teams exceeded two weeks, HomeLink’s therapists provided a vital bridging service, helping patients regain mobility, maintain independence, and reduce the risk of deterioration or readmission while awaiting longer-term care.

This expansion helped address another key challenge faced by the Trust: inconsistent community services across different London boroughs. Not all boroughs provided the same level of district nursing support, which could complicate discharge planning. HomeLink’s flexible service model helped bridge these gaps.

Impact

The collaboration between HomeLink Healthcare and Imperial College Healthcare NHS Trust delivered several benefits:

– Reduced discharge delays for patients requiring VAC therapy.

– Improved access to wound care equipment, preventing pump shortages within the hospital.

– Safer transitions from hospital to home, particularly for patients living alone.

– Reduced risk of re-admission through continued clinical oversight, with a low re-admission rate of just 2%.

– Expanded home-based treatment options, including IV antibiotic therapy through OPAT.

– Greater consistency of care across boroughs, helping to overcome variations in local community services.

– Seamless transition of patient care, through close collaboration with community services across 11 London boroughs and Hertfordshire.

Patient Outcomes

Over 1,500 patients were supported by this initiative, reducing their length of stay in hospital by an average of 8 days.

Using EQ-5D-5L, results show that patients are experiencing, on average, a 31% improvement in their self-reported health outcomes (VAS). Specific areas of improvement include

  • 23% improvement in mobility,
  • 24% improvement in self-care,
  • 6% improvement in usual activities,
  • 14% improvement in pain and discomfort, and
  • 12% reduction in anxiety and depression.

99% patients who received this service said they would recommend it to friends and family.

“Having treatment at home gave me the freedom and joy of being with family. I hope to have HomeLink every time if needed in the future. Thank you to all Nurses and Physios!” – Patient feedback

Conclusion

The partnership demonstrated how a flexible community healthcare provider can support acute hospitals in improving patient flow while maintaining high standards of care.

By bridging the gap between hospital and community services, HomeLink Healthcare enabled more patients at Imperial College Healthcare NHS Trust to continue treatment safely at home, freeing hospital capacity and enhancing patient experience.

Paul gets his reason to smile back

One of our recent patients, Paul, was living with Parkinson’s disease and depression when aspiration pneumonia and cognitive decline led to his hospitalisation on 11th February.

Needing significant support, Paul was referred to HomeLink Healthcare on 22nd February for physiotherapy. When we first met him, Paul required two therapists to assist him with any movement and used a Sara Stedy for stability.

Through intensive physiotherapy sessions, Paul began a journey to regain his strength and mobility. Over the course of the next two weeks, our focus was on helping him move safely and independently. During this time, Paul saw significant progress. His mobility score (mBarthel) jumped from 28 to 53, indicating a marked improvement in his daily activities. His self-reported quality of life score (EQ-5D-5L) also rose from 50 to 65, showing a positive shift in his overall well-being.

Originally scheduled for discharge on 9th March, with the expectation of community team involvement, the handover process took a bit longer than initially anticipated. To ensure continuity of care, we extended our visits until the transition could be completed.

Throughout his time with us, Paul’s physical progress was remarkable. His wheelchair mobilisation progressed from 0 to 8, and he successfully transitioned from using the Sara Stedy to a four-wheel Zimmer frame within two weeks. Initially requiring double-handed physiotherapy, Paul transitioned to single-handed visits by the end of our care.

Beyond his physical progress, we also witnessed a remarkable transformation in Paul’s emotional well-being. Initially grappling with severe depression and feelings of burden, with increased mobility and independence, his outlook shifted dramatically during his time with us.

His daughter expressed her gratitude for the positive impact our team had on Paul’s life, adding:

“They are fantastic! They’ve made a massive difference in my dad’s life. They put a smile back on his face and supported him both physically and mentally.”

Shortlisted for a Chief Allied Health Professions Officer (CAHPO) award

South East London AHP TeamHomeLink Healthcare have been shortlisted for a Chief Allied Health Professions Officer (CAHPO) award for their work in partnership with Lewisham Adult Therapy Team (LATT). The service saw the waiting list of 203 reduce by 85 per cent to 30 in an 18-week period. Not only that, 69 per cent of patients were seen within three days and improved patient outcomes were seen across the board.  

In October 2021 Allied Health Professional (AHP) Leads from the South East London joined forces with AHP Leads from HomeLink Healthcare to provide a collaborative approach to addressing the increasing demands on the community physiotherapy service for patients residing in the South East London regions of Lambeth, Southwark and Lewisham.  

The AHP Team drove innovation and change in the creation and implementation of a new pathway that addresses both the NHSE/I Long Term Plan and commitments to AHPs into Action. The results were increased physiotherapy capacity in the community; improved patient flow; and better patient outcomes and experience. 

The challenge 

The challenges identified by the AHP Team were as follows: 

  • The LATT therapy leads reported an increase in demand from referrals for patients requiring community physiotherapy.  
  • They cited workforce concerns preventing them from meeting their referral demands along with an increase in the use of agency staff thereby driving up costs and potentially reducing quality and effectiveness. 
  • LATT were experiencing an increase in staff burn out, sickness and challenges balancing annual leave and staff training. 
  • LATT reported a waiting list of 203 patients, with patients waiting more than six months for a therapy review. 
  • Concerns were raised that patients were being admitted to hospital on account of not receiving timely physiotherapy support to maintain them safely in their own homes. 
  • The patient experience was poor due to increased waiting times for therapy input. 

Aims, outcomes, and ways of working to overcome potential barriers 

Aims 

AHP-logoA set of SMART aims for the pathway were co-created to improve patient flow and physiotherapy capacity for patients living in the Lambeth, Southwark and  Lewisham localities. 

  • Provide a responsive physiotherapy service that delivers efficient and effective  patient centred physiotherapy treatments to maintain them safely at home. 
  • Reduce waiting list of community physiotherapy. Prior to the service, 203 patients were awaiting therapy. 
  • Improve patient outcomes by increasing mobility and functional independence. There were no standard clinical outcomes in circulation. 

Outcomes 

  • A shared vision of quality improvement across all pathways made it possible to mobilise the pathway in just 4 weeks.
  • 69 percent* of patients were able to be seen within three days of (non-urgent) referral (*based on patient choice). 
  • The waiting list was reduced by 85.2% to just 30 patients in just 18 weeks. 
  • Positive outcomes in mBarthel and EQ-5D-5L measures.   
    • mBarthel increased from 76.5 to 87 
    • Self-reported health state (VAS) increased from 54.4 to 67.6 
    • Self-reported EQ-5D-5L figures improved in all dimensions (note a decreasing score is an improvement) 

EQ 5D 5L

  • Quality improvement was delivered and measured with data regularly shared by the AHP Team to support wider MDT collaboration. These outcome measures are now adopted as standard within SEL.  
  • As a result of shared learnings 4x as many patients are benefitting from the new pathway in South East London. 
  • The service has spread across the System. From Lambeth and Southwark, the model has been reused in Lewisham, Bromley and Woolwich with learnings shared in other ICSs. 

How did we do this?

  • AHPs worked collaboratively. Regular review meetings were held to ensure quality and safety. 
  • An operational manual was co-produced with wider MDT to ensure effective and efficient governance. 
  • We agreed patient specific outcome measures in order demonstrate quality improvements. 
  • Wider system partners were involved in order to increase shared learning practices and collaboration to safely deliver 240 visits per week 

Transferable lessons learned:

  • Workforce retention and recruitment strategies are essential to ensure longevity to new services. This pathway enabled a 66% increase in capacity for staffing which allowed teams to take annual leave and manage COVID-19 isolations whilst providing continuation of care to patients.  
  • Involving Consultant bodies and wider system partners from the outset is essential to optimise referral and discharge processes. 
  • Being comfortable having open and honest conversations with colleagues for the benefit of the patient has enabled improved outcomes. 
  • Regular knowledge-sharing and reporting are vital for optimising patient outcomes. 
  • Ensure the whole AHP/MDT team is involved in the journey, so the service is driven by those who deliver it. Recognising the value of different knowledge and skills that staff of all levels can add. 

Adeola Telesford, Highly Specialist Rehabilitation Occupational Therapist from Enabling Services, Lewisham and Greenwich NHS Trust commented:

“I am truly pleased with the professional relationship/rapport we have built because it has enhanced our regular verbal and written feedback on cases.

I am particularly pleased by the fact your service has been able to visit patients in a timely manner (within 24-48hours of receiving the referral) and to carry out pre-planned joint visits with me. Timely intervention, which I have found with a number of cases, made a significant positive impact on the SMART goals that were set for each patient.

It was refreshing if not amazing to see how the combined intervention of PT and OT input complimented each other. Your service input proves the validity in having PT and OT working alongside each other in a service of this nature when working towards a time frame of maximum 6 week interventions. I look forward to continued working with you”.

NHS Shared Business Services (NHS SBS) framework agreement renewal enables direct commissioning of Hospital at Home services

We are pleased to announce we have been reappointed as a supplier on NHS Shared Business Services (NHS SBS) Patient Discharge and Mental Health Step Down Beds Services Framework Agreement. NHS partners can procure services with HomeLink Healthcare directly via the framework agreement.

 

New NHS SBS Framework Agreement

About the framework agreement

This NHS SBS framework agreement has been developed to reduce the demand on NHS Trusts by supporting with their adult patient discharge pathways. The framework agreement aims to:

  • facilitate transfer of patients from hospital beds to a more appropriate level of care
  • supply additional bed capacity within the NHS urgent care system infrastructure by relieving bed pressures within the local health economy
  • discharge patients meeting specific clinical criteria into an appropriate care setting, reducing instances of re-admission to hospital
  • allow patients to have personalised on-to-one support maintaining continuity of care
  • provide a dedicated pathway to hospital discharge management services.

HomeLink Healthcare is a supplier on the following Lots:

  • Lot 1: Discharge to Assess Services: facilitates patient discharge not only from emergency departments but also from the wider acute hospital and community care settings.
  • Lot 3: Virtual Ward Support Services: supplies a “secondary care” service within a patients care setting for up to 6 weeks. Patients are transferred to the Virtual Ward Support Service following referral from the Trusts’ clinical discharge teams on acceptance by service leads.

“Free to access, our ‘Patient Discharge and Mental Health Step Down Beds Services’ framework agreement is designed to support the transition of patients from hospital, reducing instances of pressure on acute hospital beds, Social Services and re-admissions. In turn, this enables health and care providers to free up capacity to deal with other patients. improve quality of care and health outcomes.” Elaine Alsop, Head of Category – Health, at NHS SBS.

Avoid delays and contract with us directly

NHS partners can use the NHS SBS Patient Discharge and Mental Health Step Down Beds Services framework agreement to directly award contracts to HomeLink Healthcare, saving time and money on the procurement process.

New services can be mobilised in 8-12 weeks. Act now to get a new service up and running within three months and at full capacity within around four months.

  1. Develop specification, business case, contracting options and supplier engagement: now!
  2. Contracting: one week
  3. Service mobilisation: twelve weeks
  4. Go live!
  5. Ramp up to full capacity: six weeks

Work with us

HomeLink Healthcare has been delivering Hospital at Home services since 2016. As a supplier to NHS SBS’s new framework agreement and its previous iteration which ran for four years from March 2019,  it has been used to procure a wide variety of pathways from a large number of organisations including Trusts and the Community Services.

Find out more about the process of commissioning HomeLink Healthcare to set up a hospital at home service.

Get in touch

To speak to a member of our team about our services, call us on (020) 3137 5370 or contact us. You can tell us about your situation, and we can tell you more about our experience of supporting our NHS partners and how we might be able to help you.

 

Release in-patient bed capacity this winter with Hospital at Home services

The case for Hospital at Home services is compelling. Seasonal resilience funding is often seen as a one-off. Why not use it to work with an experienced provider which has a track record of delivering results for the NHS and for patients. HomeLink Healthcare can also help with business planning now. This will speed up the process of delivery once funding is released.  

According to the Delivery Plan for Urgent and Emergency Services the winter crisis of 2022 saw hospitals fuller than pre-pandemic levels, with 19 out of every 20 beds occupied and 7.2 million patients on waiting lists. In January 2023, nearly 14,000 beds were occupied by patients who were fit to be discharged.  

This winter is expected to see similar challenges. With bed occupancy rates over 90%, hospitals are increasingly looking towards Hospital at Home services to free up beds ahead of winter. 

The case for Hospital at Home services is compelling

"Boosting care in the community and treating more people at home is key to recovery – it is better for patients and their families, as well as easing pressure on NHS services."
- Amanda Pritchard, NHS Chief Executive

NHS England sees Hospital at Home and Virtual Wards as a key solution to improving patient flow through A&E and reducing elective recovery waiting lists. According to statistics patients are five times less likely to acquire an infection and eight times less likely to experience functional decline on a Virtual Ward compared to an acute setting. Twenty-three per cent of these patients also achieve a more independent social care outcome. 

HomeLink Healthcare provides Hospital at Home services through a number of pathways including Early Supported Discharge, Discharge to Assess, Virtual Wards, Reablement, Rehabilitation, Anticipatory Care, and Bridging Packages of Care. 

Seasonal resilience funding can relieve the pressures and build a case for future roll-out 

As Hospital at Home services become more established, and increasing numbers of patients are seen at home, savings can be made through introducing fewer hospital beds and outsourcing less elective care procedures to the private sector.  

Setting up a Hospital at Home service doesn’t need to be difficult

A Hospital at Home service requires expert knowledge; integration with existing governance structures; staffing; and in the case of Virtual Wards, technology. We understand that this can be quite daunting, particularly at a time of such immense pressure.  

That is where HomeLink Healthcare comes in.  

  • EXPERTISE IN HOSPITAL AT HOME: We are 100% focused on delivering Hospital at Home services and have been since 2016. We have numerous clients and we deliver services in four of the seven NHS England regions. 
  • COMMITMENT TO QUALITY: We are clinician-run and everything we do is patient-centric. Our clients see us as ‘NHS like’ and in our most recent client survey we received 100% client satisfaction. 
  • NO NEED TO RECRUIT: We bring with us a multi-disciplinary team of compassionate, patient-focused nurses, therapists and healthcare support workers. 
  • TECH, OR NO TECH, NO PROBLEM: If you’re interested in a Virtual Ward, we can provide our own technology partner, or work with your existing technology supplier. 
  • FAST, EFFECTIVE MOBILISATION OF SERVICES: Services can be procured directly using the NHS Shared Business Services Patient Discharge and Mental Health Step Down Beds Services Framework. We use a PRINCE 2 project management approach, supported by a dedicated project manager and can get brand new services up and running within 12 weeks.  
  • WE WORK IN PARTNERSHIP: We bring our expertise and tried and tested ways of working and at the same time treat each relationship on a case-by-case basis. We have been shortlisted for three HSJ Partnership awards.  
  • REAL-TIME DATA: Advanced KPI reporting enables clients to see what is happening in real-time and share best practice. Data includes patients, visits, outcome measures and patient experience metrics 

We can help you to increase hospital discharges in time for winter

HomeLink Healthcare can get a brand new service up and running within 12 weeks. This means that if you act now, you can have new pathways in place by winter 2023/24.  

No funding yet? Don’t let that stop you from contacting us!

We know that funding for winter is on its way but that you might not know how much you will receive. To avoid unnecessary delay, and to make things easier for you during the procurement phase, our staff can carry out a no-obligation feasibility assessment now. The outputs from this can also be used to help pull together a business case. After funding levels have been agreed, we can adjust the numbers accordingly.  

View our case studies:

  • Last year we implemented new Bridging Packages of Care and Reablement pathways in Buckinghamshire. Discussions started in the summer before funding was in place, and the service commenced on 1 December 2022. The service saved 951 bed days its first 18 weeks. Read more here 
  • A patient in Norfolk gets home in time for Christmas thanks to the Virtual Ward. Read more here  
  • Hospital at Home services in Norfolk and Waveney save the equivalent of two hospital wards every day. Read more here.  

Work with us

Find out more about the process of commissioning HomeLink Healthcare to set up a hospital at home service.

Get in touch

To speak to a member of our team about our services, call us on (020) 3137 5370 or contact us. You can tell us about your situation, and we can tell you more about our experience of supporting our NHS partners and how we might be able to help you. 

 

In-reach physiotherapy service in care homes benefits patients and hospitals

At a system level an in-reach re-ablement service is a safer and lower cost option for the ICB than providing 24/7 care and physiotherapy in the patient’s home.

In order to free up hospital beds and improve patient outcomes, Norfolk and Waveney Integrated Care Board (ICB) spot-purchase beds in care homes for patients who need up to four weeks’ re-ablement.

HomeLink Healthcare has been working in partnership with hospitals across Norfolk and Waveney since 2019 to provide Hospital at Home services. In February 2023 the ICB commissioned HomeLink Healthcare to provide an in-reach re-ablement service in care homes.

The in-reach reablement service means that patients from James Paget University NHS Hospital Trust can be discharged when they are deemed medically fit and would benefit from ongoing reablement before they are able to return home.

Virtual WardPatients are assessed by a HomeLink Healthcare physiotherapist in the care home within 72 hours of admission and start receiving physiotherapy and re-ablement immediately. The physiotherapist designs an individualised re-ablement programme, which is delivered by re-ablement support workers, and reviewed as needed by the physiotherapist. The team engage with and encourage care home staff to support patients with their exercises between visits.

The HomeLink Healthcare team attend the weekly multidisciplinary meetings to facilitate discharges and refer onto other community services including social services and community physiotherapy, ensuring patients ongoing care needs are met when they return home.

Patients returning home after receiving re-ablement services in a care home are typically more independent when they return home. As a result they need less ongoing support and smaller ongoing packages of care that than they would have needed without the service.  

On average patients in the Norfolk in-reach re-ablement service have seen 11% improvement in their mBarthel score and a 19% improvement in mobility in their self-reported EQ-5D-5L score.

At a system level, an in-reach reablement service is a safer and lower–cost option for the ICB than providing 24/7 care and physiotherapy in each patient’s home. 

More information about our In Reach service in Care Homes can be found here.

Patient stories 

Sam:

Sam is a long-term smoker who lives alone in a second-floor flat. He had an acute kidney infection followed by COVID-19 as an in-patient. This resulted in him needing thrice-weekly kidney dialysis due to kidney disease. Prior to hospital admission Sam was fully mobile and independent in all activities of daily living.

Sam was discharged from hospital to a care home for re-ablement. Sam presented with shortness of breath on exertion which limited his ability to walk any distance and to climb stairs. He was also anxious about getting short of breath and lacked confidence about climbing stairs alone after a long hospital stay.

When Sam became medically fit for discharge, there were concerns around his ability to manage at home independently and Sam was therefore transferred to a care home to receive ongoing support. In the care home a HomeLink Healthcare physiotherapist assessed Sam within 24 hours of arrival and provided Sam with a series of stamina and muscle strengthening exercises. In between Sam’s therapy visits a HomeLink Healthcare re-ablement support worker carried out sessions to increase Sam’s confidence and also involved stair practise. This enabled him to improve his stamina and confidence following his illness which had led to Sam feeling deconditioned.

Sam was very pleased with his progress as he reported feeling stronger in general. Following completion of his re-ablement package he was able to manage the two flights of stairs required to be able to return home to his flat. The HomeLink Healthcare team ensured that a package of care was arranged to help with shopping.

Glen:

Glen had bilateral fractures of his pubic rami. This resulted in an enforced period of bedrest. He was unable to weight-bear and required a hoist to transfer. Glen’s past medical history included diabetes and long-term leg ulcers due to peripheral vascular disease and neuropathy.

Prior to his hospital admission Glen had been independently mobile with a frame and had been independent in all activities of daily living.  He lived with his partner, but in order to return to their new property, Glen needed to be independent with his bed mobility to support his toileting needs at night and his functional independence.

Glen was discharged from hospital into a care home for short-term re-ablement. When a HomeLink Healthcare physiotherapists assessed Glen in the care home he was starting to transfer a few steps with his frame with some support. Pain, along with the poor skin condition of his legs and toes, was however impacting on his rehabilitation.  The pain was addressed and the physiotherapist provided a course of strengthening exercises as well as bed mobility and functional activities such as accessing the bathroom and completing toilet transfers.

The physiotherapists along with a HomeLink Healthcare re-ablement support worker also worked on Glens balance within the limitations of toe pain and building stamina and confidence with his frame. Following the completion of his re-ablement package Glen became independently mobile with the frame and with bed transfers and toileting.

Glen said that he felt the service had improved his strength and confidence. He also felt positive that he and his partner could manage on his return home.

Through attendance at the weekly multi-disciplinary meeting HomeLink Healthcare facilitated an Occupational Therapy Assessment, issue of equipment, and the provision of a package of care for personal care only. Glen was then able to return home safely.

About HomeLink Healthcare 

HomeLink Healthcare is a clinician-led, specialist Hospital at Home service provider.  We have been delivering safe, high-quality services to NHS patients in the place they call home since 2016. 

HomeLink Healthcare have successfully delivered this service in care homes in Norfolk and South East London and would we are able to replicate this service in other commissioned services where we provide a physiotherapy-led service. 

Work with us 

Find out more about HomeLink Healthcare’s Hospital at Home services and the process of commissioning HomeLink Healthcare to set up a hospital at home service. 

Get in touch 

To speak to a member of our team about our services or to book a FREE feasibility study, call us on (020) 3137 5370 or contact us.  

Physiotherapy at Home reduces care costs by over 65%

In Fred’s case this intensive physiotherapy resulted in a happier patient, roughly a 65% reduction in care and a saving in care costs of over £1,000 per month.

Fred (not his real name), who is in his 80s, lives at home with his wife. In recent years he has had multiple health problems and in September 2021 had a bad fall and was admitted to hospital. Fred’s son, says that his father then contracted Covid several times. At one point the family were called to the hospital as doctors thought Fred was near the end of his life. When, in April 2022, Fred was discharged home his Barthel score was 15, indicating total dependency. Care was provided by a domiciliary care agency and he needed two carers, three times a day, seven days a week. In May, Lewisham Adult Therapy Team (LATT) referred Fred to HomeLink Healthcare to provide physiotherapy support.  

Shirley Forson, HomeLink Healthcare’s Clinical and Operations Lead for Therapies, says: 

“We first supported Fred from May to mid-June and were commissioned to provide six double-handed physiotherapy sessions. The goal was to improve his sitting balance and to enable him to use a Sara Steady with the assistance of a single carer, as he was previously mobile with a Zimmer frame. At the end of six sessions he was discharged having made a small gain, but given the limited number of sessions he didn’t progress as much as he could have done.” 

"The more independent dad can get the better. Originally, he had two carers three times per day. Now one carer comes three times a day Monday to Friday and we don’t have anyone at the weekends."
- Fred’s son

Fred was then readmitted to hospital in June with an unrelated health condition. When, after 10 days, he was discharged and referred back to HomeLink Healthcare. His mobility had deteriorated and he was “totally bed bound”.  

Shirley says:  

“We completed another six double-handed sessions, lasting until mid-July, with the same goals as the first time. Again, progress was limited.” 

Fred was then hospitalised once more and when discharged in August, was referred back to HomeLink Healthcare for a third time. We then supported him for a longer period, discharging him on November 4th after 28 sessions. This time, there was real progress.  

Shirley reports that during this third referral:  

“Fred went from being bedbound, needing double handed support and assistance with everything, to using a walking frame on his own with just someone around to give him reassurance. He can get to the commode by himself and can now get to sitting on the bed on his own, whereas previously he needed two people to help. He can also transfer on and off the stairlift with one person’s assistance, so can once again access both levels of his house.”  

Fred’s Barthel score went from 15 to 74, indicating a massive change to quality of life and independence. Furthermore, his mood has improved and he feels better about his health. HomeLink Healthcare uses the EQ-5D-5L self-assessment, health related, quality of life questionnaire. This measures quality of life over five categories: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each category is rated out of 5, with a score of 5 indicating very poor  and a score of 1 being very good. Fred’s scores improved significantly across all 5 domains as shown in figure 1 below.  

Fred's EQ5D5L score Figure 1: Fred’s EQ-5D-5L score

Shirley says: 

“EQ-5D-5L also has an overall health rating, which asks ‘How good or bad do you feel about your health’ (0 = 0 terrible, 100 fantastic). Fred started at 30 and ended up at 100.”  

This is an atypical case. Shirley says that in the LATT service therapists usually only see patients three times due to staff availability and referrals to HomeLink Healthcare are typically limited to six sessions. It demonstrates, though, that a greater investment in therapy earlier on can improve patient outcomes and reduce costs in the longer term. 

Alex Negurita Community PhysiotherapistAlex Negurita, Community Physiotherapist for HomeLink Healthcare says: 

“Fred made huge improvements between his physiotherapy sessions. It helped that he was so motivated and he really engaged with the exercises in and between sessions. I was impressed with what he was able to achieve, and I am pleased to have been able to help him to become more independent. I wish him and his family the best of luck for the future.” 

Small steps and big changes

Progress was easy to see, as each time Pat could do more than the previous visit, which was only a few days earlier. By the final session she was able to walk to her front door and back, without a frame.

In Autumn 2022 Lewisham Adult Therapy Team (LATT) referred Pat (not her real name), aged 65 to HomeLink Healthcare for six 45-minute sessions of physiotherapy, including an initial assessment. She had just been discharged from hospital with Type 2 respiratory failure. Furthermore, she had a complicated medical history including breast cancer, obstructive sleep apnoea, type 2 diabetes, asthma, and a TIA that weakened her left side. When discharged from hospital Pat was bedbound.

Samantha Rusike, a HomeLink Healthcare Physiotherapist, says:

“Pat was in hospital for three and a half weeks, and HomeLink Healthcare saw her after discharge from hospital. Pat was in a downstairs room with a hospital bed, a walking frame, a commode, a wheelchair and a new sleep apnoea machine. She could get up and sit on the edge of the bed and stand up onto the walking frame at this point her daughter was doing strip washes for her mother in bed. Pat wanted to walk independently and get to the downstairs bathroom.”

During the initial assessment session Pat could walk with her frame for about two metres if somebody followed her with a wheelchair. She would then become very tired and would need to rest and use her inhaler before moving again. The HomeLink Healthcare Physiotherapist, Samantha, worked with Pat, and together a co-produced physiotherapy programme was developed to build up Pat’s exercise tolerance. As well as practising in the sessions, Pat was given exercises to do in her own time. Pat’s daughter was encouraged to attend most of the sessions and supported her mother to do the exercises in between sessions.

In many physiotherapy services, a patient is seen once and given some exercises, and then not seen again for sometimes up to a month. The impact of the physiotherapy depends a lot on whether the patient can maintain the exercise plan. In this case, twice weekly visits helped establish a rapport between Pat, her daughter and Samantha. At each session Samantha encouraged Pat to walk further and do more exercises. Progress was easy to see, as each time Pat could do more than the previous visit, which was only a few days earlier. By the final session she was able to walk to her front door and back, without a frame. She was also showering, with her daughter’s support.

Samantha says: “When patients have one session a month and then don’t do much, it’s hard to monitor and see the progress. When they are seen twice a week it is easy to see if someone hasn’t done their exercises or if they are struggling and need their programme modified.”

As part of the initial referral, HomeLink Healthcare was asked to assess what extra equipment Pat needed. For example, she wanted a bed lever so she could pull herself up. But by the end of the sessions she didn’t need this or any extra equipment. She was more confident moving about the house and more independent with washing.

Pat says:

“When Samantha came she helped me walk much further than I had walked in 4-5 years. My daughter is trying to carry on Samantha’s great work. Some days I am really tired, but my daughter and my two-year old granddaughter egg me on to do the exercises. Having encouragement makes you want to do things. I’m much better at walking now – I can do lots of things myself. I can get up from the bed by myself (no help needed) and I can use the commode on my own (in hospital I had to use a bed pan).”

Pat’s daughter adds:

“Samantha was really encouraging and patient with mum. When mum reached a small goal, she added something else. The small encouragement meant a lot.”

These changes in Pat’s life might seem like small steps, but they have had a big impact on her independence and wellbeing. Pat reflects “I nearly died when I was in hospital and I am so grateful to everyone at the NHS and HomeLink who helped me to get to where I am today. That’s why I want everyone to see my story and how the NHS and HomeLink Healthcare helped me” she says.

Within a few weeks Pat got to the stage where she could be discharged from the community physiotherapy team’s list. The impact on patient flow would be significant if that outcome were multiplied across many more people.

Samantha concludes:

“We have very few patients coming back for a 2nd time because of the level of initial input we can give. HomeLink Healthcare can help with these patients over five or six sessions, so that they don’t have to come back again.”

Celebrating AHPs Day

AHPs are the second largest workforce within the NHS.

Every year on the 14th October – Allied Health Professionals (AHPs) come together to celebrate being part of the AHP family. It is a social movement that enables AHPs from different backgrounds and organisations to collaborate within and outside of their services, organisations and regions.

The 14th day of October was chosen to represent the 14 different AHP Professions.

AHPs play a crucial role in government policies and transformational care, with significant opportunities to support the delivery of the NHS long Term Plan, focusing on:

  • Preventing ill health and supporting healthier lives
  • A safe, high-quality service
  • Transforming out of hospital care
  • Supporting and ensuring collaborative and integrated working with acute and community services
  • Supporting improvement in efficiency and productivity

Do you know which professions makes up the AHP family? The are 14 – how many can you name?

Here is the full list:

– Occupational Therapists         – Physiotherapists         – Dietitians         – Radiographers         – Podiatrists/Chiropodists

– Prosthetists and Orthotists         – Drama Therapists         – Music Therapists         – Art Therapists        – Paramedics

– Operating Department Practitioners          – Orthoptists        – Osteopaths       – Speech and Language Therapists

I am proud to be an AHP and I have had the opportunity to work with a variety of AHPs during my career. The COVID-19 pandemic has truly put our professions under the spotlight and demonstrated just how important and valuable our AHP workforce is.

I want to say a big thank you to all of our AHPs colleagues who we work with directly and indirectly.

April Thompson. Head of Therapies at HomeLink Healthcare

Discharge to assess with HomeLink Healthcare. Retaining the positive improvements from the pandemic

While Covid-19 has thrown much of society into disarray and caused monumental damage to hospitals, healthcare workers and their patients – in healthcare, there have been some positive changes. One of these is in the altered attitudes toward hospitals and home-based care. Another is in the rapid rollout of crucial services that ease pressure on hospitals and make for better patient experiences. At HomeLink Healthcare, we believe it is essential that these changes remain – pandemic or not.

Aims of Discharge to Assess home-based services

AssessmentAttitudes towards hospitals have been shifting for some time. Historically, both doctors and patients operated under the belief that the patient was best cared for in the hospital. This led to extended stays; the remedy for any illness, a hospital visit; prolonged periods in the ward even after a patient was fit to return home.

Covid-19 was the catalyst of a new way of thinking: avoiding hospital admissions in the first place where possible; getting people home faster in every other case.

For patients, in the heightened context of the pandemic, fear and avoidance of hospitals has become widespread. Numerous statistics underpin this. For overstretched and overburdened healthcare workers, the ability to relieve beds for urgent patients is critical.

The UK government has also taken note. In 2020, Discharge to Assess (D2A) was launched in hospitals across the country. The aim? To discharge all patients who no longer met ‘acute criteria’ as soon as clinically safe to do so, and where possible, to avoid hospital admission to begin with. Assessments take place at home, rather than at hospital. It has been found to not only be possible, but beneficial.

At HomeLink Healthcare, we provide D2A as part of our home-based services, It is an integral part of how we work and our ethos as an organisation.

We always see our patients within 24 hours, ideally on the same day of discharge.

HomeLink’s D2A Service at The Queen Elizabeth Hospital King’s Lynn

We were pleased to partner with The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust (QEHKL) to create a harmonious D2A service to improve patient flow in their wards and reduce capacity challenges. Being a small and agile company brings a number of advantages to our partnerships. We are able to set up and deploy supporting services rapidly: our D2A with QEHKL was one of the quickest services we’ve ever delivered, with just a four week mobilisation period until it was fully up and running, using the NHS SBS Patient Discharge Services framework for procurement and contracting was essential to achieve the tight timescales.

For patients, that meant we could get many of them back home for Christmas. Since then, we have rapidly ramped up the service, and it continues to go from strength to strength. We were one of the first homecare providers to flex our services to accept Covid-positive patients. A core element of how we work is as a bridge organisation: not replacing existing systems or provisions but complementing and enhancing the care provided. That means all our services are bespoke, moulded to the needs of the particular hospital. Whether we’re providing increased capacity or improving the efficiency of processes, we align ourselves with existing hospital and community practices as much as possible. And as a small company, we can do that efficiently, cost-effectively and most importantly; safely.

Key to this is open, transparent and supportive communication. At QEHKL, this meant visiting the wards or speaking with the therapists, building rapport with the therapy-leads, frequent team and stakeholder meetings, and giving constructive feedback on how patients were progressing and any issues encountered.

Similarly, we ensured we made positive connections with the community therapy teams; reiterating that we exist to fill the gaps, not replace their services. We recognise the strain they are under and their huge waiting lists – so how could we best complement that service and really place patients at the centre? Now, if the community team has patients that need to be urgently seen and they are unable to support, they send them to us, knowing we can assess them in 24 hour and feedback any recommendations or provide the input required.

In the words of Tim Rees, Professional Lead Occupational Therapist at The Queen Elizabeth:

“HomeLink has been a marvellous asset to our service at the hospital. Their therapy team has worked seamlessly with our therapy teams in the development of the Discharge to Assess model. The communication, expertise and support they have brought to the project has been invaluable. The feedback has always been positive and non-judgemental which has fostered team spirit rather than creating an atmosphere of them and us.”

Holistic home-based care: Putting patients first.

So how does it work?

The Queen Elizabeth community response team identifies medically optimised patients and flags them to our service. We then contact the ward, discuss the discharge plan for the patient and the D2A process is commenced. Our home assessments are undertaken by either a registered nurse or one of our expert physiotherapists.

Our holistic home-based assessments encompass examining the health, wellbeing and social care needs of each individual. From there, we determine what package of care prescription they need – whether it is once, twice, three or four times a day – and then our specialist team delivers that personalised wrap-around care.

Our approach is one of enablement: we work alongside the individual to help them manage their daily personal care. The care we provide varies. It might be washing and dressing, meal preparations, supermarket shopping, medication prompts or provisions. We help them to complete their domestic tasks: supporting our patients to clean their property, look after their pets. The therapy element focuses on reablement and rehab: progressing their mobility, increasing their confidence, and modifying walking aids and equipment. During our assessment, we undertake a rapid review of what existing equipment is in the home and what additional equipment we could put in place – perching stools, kitchen trolleys – to enhance independence and reduce the required package of care.

In one case, an elderly gentleman was referred to our service for therapy only. On post- discharge assessment, we realised he needed a package of care, not just therapy. We initiated morning visits: helping him with his washing, providing physiotherapy, and communicating with the community response team so that they were then able to source a care team to take over his needs.

Patients’ rehabilitation

For patients, one of the consequences of Covid-19 is that they now receive far less rehabilitation on the ward. With the workforce redeployed to focus on acute patients, there is a significant gap in patient therapy provisions. We are seeing more people leaving hospital weaker and more deconditioned – not having received the therapy they would normally have received before the pandemic. This risks serious long-term effects on an individual’s confidence and independence.

In some estimates, for every 24 hours a patient stays in bed they lose 1% of muscle mass.

In others, 10 days of bed rest was found to lead to a 14% reduction in leg and hip muscle strength.

12% reduction in aerobic capacity: equivalent to 10 years of life.

Even with rehabilitation in place, prolonged hospital stays incur damage to patients, particularly the elderly.

We work to bridge that gap and get patients home faster: helping them reach a point where they are safe, independent and at ease – until a community therapist can take over.

Recovering at home:

Better for the patient and the hospital

There are a number of reasons why we believe the Discharge to Assess service is so important – and why discharges should continue to be done in this way post-pandemic. In terms of a hospital’s operational flow, bed flow through the trusts can be reduced and capacity dramatically eased by utilising out of hospital services like ours. This frees up beds to provide space for new acutely unwell patients, it enables hospitals to recommence elective activity, and in using the service for admission avoidance, reduces the burden on the front door. Financially, it’s cost-effective – home services are cheaper to run than an equivalent hospital bed.

Ultimately, and most importantly, is the patient’s care: we believe in putting patients first, always, and to do this, we believe the best place for them to recover is in the comfort of their own home.

As April Thompson, HomeLink’s Head of Therapies, who leads the QEHKL D2A service, says:

“One of the positive things to come out of the pandemic is how services have adapted (at pace) to meet the changes and demands of patients needs. It has strengthened relationships and fostered new ways of working. The pandemic has enabled clinicians to think differently about how to provide care and what can be delivered in the community setting. It comes down to patient care and putting them first. Everybody knows the best place for them to be is in their own home.”

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Work with us

Find out more about the process of commissioning HomeLink Healthcare to set up a Hospital at Home service.

Get in touch

To speak to a member of our team about our Hospital at Home services, call us on (020) 3137 5370 or contact us. You can tell us about your situation, and we can tell you more about our experience and how we might be able to help you.

Got a question? Contact us on (020) 3137 5370

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