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 ask about the services people receive and their recovery journey. So far, we have tracked five people along the three routes listed on the right.

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 January 2016, we were asked by Southwark and Lambeth Integrated Care to gather feedback from people taking part in a pilot 'Discharge to Assess' project. The pilot involves transferring patients who are medically fit for discharge to an extra care housing facility in Lambeth. Participants stay in a furnished flat for up to six weeks to see how they manage within an independent living environment before either returning home or moving somewhere that can better meet their needs. The pilot and our role in it, is continuing until March 2017, 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