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.
Patients 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.
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 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.
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.
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.
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.
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