Joined-up work demonstrates compassion and helps avoid two hospital admissions

Case study Hospital at Home, Patient experiences 22nd Jan 2024

HomeLink Healthcare accommodated a couple’s return to their own property following a hospital stay. Whilst providing a package of care for both parties, and IV treatment for the wife, we supported the couple through multiple additional issues which were not initially identified.

Whilst the multi-disciplinary team were constructing a longer-term plan, the HomeLink team recognised where and how the couple were struggling and prevented two hospital re-admissions.   

Aneta, who is her husband Jim’s main carer had been in James Paget University Hospital receiving treatment for an infection and fatigue. When Jim and Aneta were discharged from hospital on 30th October 2023, HomeLink Healthcare were asked to provide Aneta with a once-a-day package of care as well as IV therapy for six weeks. Jim also required a twice-a-day package of care. 

On the first visit HomeLink staff identified that both patients were struggling being at home and that Aneta had pain that was poorly controlled. Aneta’s pain was distressing Jim, which in turn upset his wife. The situation required more input that first expected.  

On 2nd November the couple were waiting social worker allocation and a concern with safeguarding was also raised.  The visiting HomeLink nurse went to the patient’s medical practice, raised concerns with the GP and organised a complex needs assessment joint visit with the GP for both parties, concentrating on pain management for Aneta. HomeLink staff stayed for longer than the allotted time with the couple offering support, caring and liaising with the multi-disciplinary team to resolve the concerns. It was decided that extra visits would be allocated to the patients to ensure they were safe and supported. 

On 3rd November Aneta had developed a urinary retention due to the pain and required re-catheterisation by the community nurses.  The medical consultant at James Paget University Hospital asked for our team to continue to monitor for mobility decline. An urgent MRI was booked.  

On 10th November following daily contact with visiting staff, the HomeLink Clinical Lead visited the patients at home with their GP and Social Worker.  Aneta’s pain management was reviewed and changed to a transdermal pain patch. The Social Worker suggested the use of respite care for the couple to allow the wife to recuperate whilst not needing to care for her husband.  

HomeLink continued to support the couple until respite care was sourced, reducing the number of visits required over time.  

This story demonstrates HomeLink Healthcare’s commitment to providing a safe, effective, caring, responsive and well-led service. The staff involved demonstrated our values of Compassion; Commitment to Quality Care and Collaboration. It also shows how providing excellent multi-disciplinary support through one provider enhances the patient experience and provides system benefits to the NHS through admission avoidance which in turn improves hospital flow and saves the NHS money. 

Find out more about the features of a HomeLink Healthcare Hospital at Home service 

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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 and how we might be able to help you. 

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