I'll be home for Christmas - ensuring a smooth transition from hospital to home

Earlier this month, NICE published a new guideline called "Transition between inpatient hospital settings and community or care home settings for adults with social care needs", which includes recommendations to improve people's experience of admission to, and discharge from, hospital by better coordination of health and social care services. 

In the Health Lab, we are currently exploring the same topic through our Centre for Social Action Innovation Fund (CSAIF) with services like the British Red Cross’s First Call, and through our Helping in Hospitals programme with "home from hospital" and "discharge buddies" volunteer roles.

We are backing these services and programmes because we inherently know how critical they are for people in distress and in crisis; people who are entitled to coordinated and continuity of care; people who might need a bit of reablement support to get them back in the routine of life - people like Mr. and Mrs. Smith*. Here is their story: 

Mr. and Mrs. Smith are 80 and 76 years old, respectively. They live in one of the many isolated villages surrounding Oakham.

Mr. and Mrs. Smith were referred to the British Red Cross's First Call service on 20th August 2015 by the district nurse team based at Rutland Memorial Hospital. The couple had been involved in a serious car accident in June, and had been rehabilitating at their daughter’s home for the previous eight weeks with additional rehab sessions at the hospital.

An initial visit with the couple took place on 24th August 2015 (a day before the couple would return home) by a British Red Cross volunteer, Anna*. The concerns the couple had regarding their return home were: i) managing the household tasks including shopping due to the effects of the injuries, and ii) managing their finances. In that visit, Anna discussed how she and the First Call service could support Mr. and Mrs. Smith with their transition home and it was agreed that she would visit the couple on a weekly basis to help with their concerns. 

During Anna's visits with the couple, light housework tasks were completed such as hoovering, and doing the weekly shop. A chat with both Mr. and Mrs. Smith always took place and it became apparent that Mrs. Smith was starting to feel the emotional impact of the accident. Anna was then given permission by the couple to contact their daughter to discuss possible solutions.

Anna worked with the daughter to discuss options for local services and a decision was made to make an appointment for Mrs. Smith to see a counsellor. Several appointments have now taken place and Mrs. Smith feels that progress is being made.

The couple have stated that the First Call service has made a big difference in their ability to settle back into their own home, and regain a level of independence.

This is one of many success stories from the British Red Cross's First Call service. The service includes practical and emotional support for people like Mr. and Mrs. Smith at a time of crisis (such as a hospital discharge) by a highly-trained Red Cross volunteer for a 12-week period. We will be publishing the full evaluation from their scaling programme through CSAIF in the summer of 2016. For more information on First Call or other British Red Cross Support at Home services, please contact your local Red Cross branch office.

*NOTE: names have been change to protect the identity of the individuals involved in the case study.


Jullie Tran Graham

Jullie Tran Graham

Jullie Tran Graham

Programme Manager

Jullie worked with a number of health and ageing projects funded through the Accelerating Ideas programme, focusing on social innovations that make it possible for people to be more in…

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