Creating a smooth transition for patients from hospitals to their homes- column by Deborah McRobbie

I work with the Discharge 2 Assess Community Team at LCHS, supporting people at home, where they would rather be and where people usually recover from illness or injury more quickly. It is also important that hospital beds are available to people who really need them.   

The team works to ensure a smooth transition for patients from hospitals to their homes. We focus on assisting patients in leaving the hospital promptly once they are medically ready. This minimises the risk of infections and prevents people from losing strength in their muscles due to prolonged hospital stays. Did you know, it is widely acknowledged that for every 10 days in hospital, a patient can experience up to 10 years of muscle deterioration?  

When a patient is discharged from hospital, we work with them to create a personalised care plan. We focus on their individual priorities and help them to access any equipment, therapy and care calls they need to help them get better. Specialists such as occupational therapists, physiotherapists, pharmacy technicians and therapy care assistants across Lincolnshire work together to help people recover both physically and mentally.  

The D2A team includes occupational therapists. Occupational therapists look at everything a person does, this can include everyday tasks that most of us take for granted such as getting out of bed, washing, walking around at home, housework and hobbies. These tasks can become difficult if we’re unwell or recovering from illness or injury and people may need help to make adjustments so they can be safe and remain independent.  

The team delivers personalised care plans with people on what matters most to them by prioritising individual needs, preferences and their circumstances, through assessing what the person requires to be safe and independent at home. Then we work with other specialist teams to support the person’s rehabilitation.   

For example, someone who has fallen resulting in a fractured hip and ankle and is unable to fully support their own weight and get up and about, is unable to get out to see friends, has a low mood and sits all day at home. Their personalised care plan would include care calls to support with personal care, setting an exercise programme, mind games for cognition, supporting the person to stay in touch with friends through social media and providing aids such as a bed lever and commode. 

I hope this has given you a flavour of how my team works and the service we provide to help people get home from hospital as soon as possible and to continue to recover at home with support from healthcare professionals.