UPDATE: More Oxfordshire patients being supported to recover from hospital stay in the comfort of their own home

An Oxfordshire-wide initiative, which is helping people to return home from hospital more quickly, has delivered significant improvements for Oxfordshire patients since it was launched in November.

The initiative is called Discharge to Assess (D2A) and it enables people who have had a stay in hospital to continue their recovery in the comfort of their own home, close to the communities that support them.

The national programme brings together hospital based teams from health, adult social care, therapy and reablement to plan a patient’s best route out of hospital, as well as provide a more joined up way to receive support once at home.

Karen Fuller, Oxfordshire County Council’s Director for Adult Social Care, said: “By working with NHS colleagues we have significantly changed the way we offer support when a patient with additional needs leaves hospital.

“Our social care teams have restructured, working seven days a week to support discharges over the weekend. We’ve also significantly redesigned our care provider framework, ensuring that we have capacity in the system to support people on the same day that they return home from hospital.”

The programme is based on the recognition that people have better health outcomes when they are supported to live happily and independently within their own homes. A vision known locally as The Oxfordshire Way.

The latest weekly figures, reported to the Oxfordshire Joint Health Overview and Scrutiny Committee on Tuesday, show that of the 105 people in Oxfordshire who were medically fit to be discharged from hospital but were still considered as needing additional care support, 91 were enabled to return home to continue their recovery through the D2A pathway.

How it works:

In hospital

D2A brings together experts in health and social care in a twice-daily Transfer of Care Hub meeting. The team considers which patients are medically fit to leave hospital and return home but who may need some additional social care support once they get there.

Plans are then put in place, in collaboration with the patient and their family, to enable them to leave hospital and return home as quickly as possible.

Returning home

Under the programme, instead of remaining in hospital or being moved to a short stay hub bed to wait for long-term support to be arranged, people are offered short-term, immediate care on the day they get home through a council arranged care provider. This can range from a drop in visit to overnight (live in) support.

Alongside the care provider, a patient who has been discharged home with additional support needs will also be allocated a council social worker or occupational therapist. They can make any quick modifications to a person’s home, supporting them to recover safely in a familiar environment. This can include provision of equipment, installation of assistive technology and other minor adaptations.

They will also be assigned a council link worker who will liaise with the care providers, social workers and the patient, to make sure the process is operating smoothly.

Long-term support

Within 72 hours of returning home, people then receive an assessment to make sure they get the right type of ongoing support, tailored to their individual circumstances.

Where it is thought that someone has the potential of regaining their independence, they may be invited onto the Home First reablement programme that offers non chargeable short-term support to help people find their feet.

For some people, a more long-term care package might be needed. The council link worker will be able to offer advice about this in the comfort of a patient’s home, including having discussions about any potential ongoing care costs, to enable them to make decisions that are right for them.  

Dan Leveson, Place Director for Oxfordshire at Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board, said: “This is a significant change in the way people are supported to leave hospital and it’s great to see the initial few weeks are working well.

“By enabling more people to recover from a stay in hospital in their own homes, rather than diverting them to a short stay hub bed or convalescing in a care home, we are supporting people in Oxfordshire to regain their independence more quickly and return to their everyday lives.

"I would like to thank the hard working staff in our local health and social care teams for their commitment to this new programme and look forward to seeing further positive results in the future.”

To support the roll out of the programme, Oxfordshire County Council has significantly increased the amount of homecare hours being provided each week by more than 7.5 per cent to 31,095 hours. This is up from 28,885 hours per week last spring and 27,888 in the autumn of 2022.

Due to the success of the programme and based on evidence from the initial pilot last summer, Oxfordshire County Council has been able to reduce the number of short stay hub beds in the region, which were originally commissioned to alleviate pressure on hospital discharges.

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