Unsung heroes providing continuity of support for people on their journey from hospital to recovery at home

Meet Rachel Downey and Lynn Alexander. They’re part of Age UK Oxfordshire’s team of discharge support workers who visit older people who have been admitted to hospital in Oxfordshire, supporting them during their stay and journey back home.

Funded through Oxfordshire County Council, discharge support workers are an important part of Oxfordshire’s Discharge to Assess programme, supporting people to leave hospital more quickly to continue their recovery with additional care at home. 

“The great thing for us is there’s no time pressure. We can sit and talk with people for as long as needed”, said Rachel, who is based at the John Radcliffe Hospital in Oxford.

“That first conversation can uncover any concerns a patient may have, which aren’t necessary medical, but can potentially be really easy to fix. This can range from people concerned that they hadn’t locked the door when they went into hospital to forgetting things like glasses and hearing aids. I’ve even gone into a person’s home to find their teeth!”

Discharge support workers are available to have bedside discussions with people who have been identified as potentially benefiting from additional support, often finding solutions to reduce people’s anxieties.

And it’s not just this practical in-patient support that’s offered by Age UK Oxfordshire that’s really making a difference. During the discharge process, they are also able to offer valuable help by ensuring patients have everything they need to go home.

Lynn explained: “For some people, they’re worried they won’t have any food in the house, so we can provide a care package of essentials for those first few days.

“Before going home, we can support people to consider how their home environment is organised to ensure a safe discharge, which can include checking the measurements of their rooms to see if equipment like a hospital bed will be able to fit. It’s often about providing that reassurance that everything will be ok once they’re home and that they won’t be forgotten about.”

This is where Lynn and Rachel’s role becomes even more crucial, as they also double up as community link workers, providing continued support to people once they’ve left hospital and returned home.

By having a face to face catch up in a person’s home, community link workers are able to tailor their support in a meaningful way, providing information about groups and activities operating in the local area, to help source more long-term support options.

This plays an important part of the county council’s Oxfordshire Way vision to support people to live well and as independently as possible in their own communities.

Rachel said: “We’re all embedded in different regions of Oxfordshire and when it’s clear a person would benefit from continued community support in their local area, we can put them in touch with groups and organisations on their doorstep.

“This could be anything from an Age UK Oxfordshire support group, all the way through to singing clubs and yoga sessions. As we can take the time to get to know people, we can really listen to what would offer them the most benefit.”

Age UK Oxfordshire’s team of support workers are an integral part of Oxfordshire’s Discharge to Assess programme, which also involves staff from Oxfordshire County Council, Oxford University Hospitals NHS Foundation Trust and Oxford Health NHS Foundation Trust, working together to identify the best way of supporting a patient to leave hospital safely and quickly.

The latest statistics show the programme has contributed to a reduced length of stay for patients in Oxfordshire, with people spending on average three fewer days in hospital than last year.

Reablement figures have also improved, with 73 per cent of people who head home through the Discharge to Assess programme regaining the levels of independence they experienced before going into hospital.

Councillor Tim Bearder, Oxfordshire County Council’s Cabinet Member for Adult Social Care, said: “Oxfordshire’s health and social care teams are working closely together to support people to leave hospital quickly and safely, easing hospital flow and offering the best health outcomes for residents.

“While we rightly praise the doctors, nurses and social workers, who support people to be discharged from hospital to head back home, Age UK Oxfordshire’s discharge support workers and community link workers are a crucial and often unsung hero of the team.

“People like Lynn and Rachel spend time to really get to know patients and build up important relationships to reduce anxiety and offer reassurance around what the future steps of a hospital stay might involve. This includes the crucial role around discharge which is now enabling 23 per cent more people to leave hospital compared to last year.

“Community link workers are absolutely essential to keeping our hospitals flowing and supporting people to recover at home.”

Paul Ringer, Chief Executive Officer of Age UK Oxfordshire, said: "Our community link workers play a crucial role in the hospital discharge process by ensuring that older adults receive the necessary support and resources to transition smoothly back into their homes.

“The support they provide not only helps to reduce readmission rates but also enhances the overall wellbeing of older people when returning to their home and community.”

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