Going Home

Gathering older people’s experiences of transfer of care from hospital to home

The Going Home project follows a patient's journey from hospital to home to see how well services work together to ensure a good recovery

Why hospital discharge?

Hospital discharge has been identified as a national problem as highlighted in a special inquiry by Healthwatch England. In our own conversations with services, staff told us that feedback from patients on discharge was ad hoc or based on experiences from several years ago. If hospital discharge was to be improved, there was a need to know what the transfer of care was currently like for people after a stay in hospital, not just at one particular moment, but all along the recovery journey.

Our Approach

We decided to test out the possibility of tracking people's experiences from the moment they were ready to leave hospital for up to three months afterwards. For our Going Home pilot programme, we gather feedback from patients and their families on a weekly basis. We asked about the services people receive and their recovery journey. So far, we have tracked people along the routes listed on the right.

Going Home pilot report

Returning home to family care

During our Enter and View visit to St Thomas’ Hospital Older People’s Unit in September 2015, we met 92-year-old local resident who had been admitted after a fall. Based on the experiences we gathered from her and her daughter following her return home, NHS Lambeth Clinical Commissioning Group (LCCG) produced the film ‘Going Home’, which was premiered at a LCCG and Healthwatch Lambeth and Healthwatch Southwark transfer of care quality summit in July 2016.

St. Thomas’ Hospital Older Persons’ Unit Visit Report

Discharge to Assess

In 2016-17 we gathered feedback from people taking part in a pilot 'Discharge to Assess' project. The pilot involved transferring patients who were medically fit for discharge to an extra care housing facility in Lambeth. Participants stayed in a furnished flat for up to six weeks to see how they managed within an independent living environment before either returning home or moving somewhere that could better meet their needs. The pilot was funded by the NHS Lambeth Clinical Commissioning Group and Lambeth Council.

Discharge 2 Assess Pilot phase 2: patient and family carer interview questions

Step-down Flats

We also worked with Healthwatch Southwark to track people's experiences of a similar pilot in Southwark involving short stays in 'step-down' flats in an extra care scheme after leaving hospital. Participants received intensive support to aid their recovery and/or an assessment to decide their next move.

Healthwatch Southwark's report on Step-down scheme at Lime Tree House: the patient's perspective

King’s College Hospital Emergency Department

In the second half of 2017, we worked with King’s Engagement Team and Healthwatch Southwark to collect patient stories from older people admitted to the King’s Denmark Hill emergency department. In a lighter touch approach to the Going Home methodology, we interviewed people within days of their A&E visit to capture their feedback on A&E and then again four weeks later to track subsequent transfer of care experiences.

Red bag scheme

Local hospitals have joined together with care homes in Lambeth to introduce the 'red bag' scheme. The red bag helps to provide a prompt, safe and efficient transfer of clinical care, when a resident moves between a care home and other clinical settings, such as hospitals. Over the summer 2018 we will gather feedback from care home residents, in the borough, and their families. We will conduct interviews with patients who were recently admitted to hospital with a red bag to explore how they found their hospital stay, their views on the red bag and briefly, whether they have had experience of advance care planning.