A person-centred, partnership approach to hospital discharge in Sefton

Urgent Care Services in Sefton have been working in close partnership with the local voluntary, community, faith, and social enterprise (VCSFE) sector to help reduce hospital admissions, enable safe and timely discharge, and support unpaid carers.

A key element is Sefton CVS Hospital Discharge Service which supports people to settle back at home following discharge from hospital or other similar health settings. It provides free, practical support for up to six weeks to help reduce the likelihood of unnecessary readmissions to hospital. This includes help with shopping, access to Careline or assistive technologies, regular welfare telephone calls, home visits and feedback to clinicians on the outcome of referrals.

The team also works with Sefton Carers Centre to provide this holistic wrap-around support, not only for patients coming home from hospital, but also their unpaid carers. They work closely with the individual and their carer to identify their needs and develop a bespoke support plan. This approach puts the carer and patient in the centre of their support and promotes choices to give them the right support, at the right time, to keep people independent and at home.

Another solution developed by the partnership is the High Intensity Use of Service Team which aims to identify what is driving repeat attendances to A&E and helps guide individuals to more suitable alternative support.

That can include help from the Sefton Crisis Cafés which deliver person-centred, non-clinical, out-of-hours support for those at risk of suicidal thoughts, homelessness, people escaping domestic violence and people who are struggling with their mental health.

Additional resource is also provided via Sefton Carers Centre’s expanded NHS partnership which enables people to access one-off personal health budgets to help with timely and effective hospital discharge – such as paying for home items like a microwave, bedding or clothes.

What is the impact?

Sefton has a very diverse population, which includes some of the most affluent and deprived areas in the country. This can pose real challenges for the effective commissioning and delivery of urgent care services – but close partnership working has been key to the effective design of these people-centred solutions.

The development of these services has strengthened links with wider system partners and enabled greater knowledge exchange across organisational boundaries. The services the partnership provides are low cost and high impact, but are not able to be delivered by the NHS alone.

The partnership has also helped identify and tackle further support needs, such as Sefton Carer’s Centre’s work with personal assistants and personal health budgets. Working across system partners has led to a holistic, people-centred approach to health and care in Sefton which has improved the experience of those using services, and their carers.

To date, the partnership has:

• Supported over 850 people being discharged from hospital or similar health settings
• Provided a same day response to every referral received during operational hours
• Kept the readmission rate for people referred to the Sefton CVS Hospital Discharge Service below 5%
• Supported applications for benefits and grants totalling over £250,000 between May 2022 – March 2023. For example, the team have helped people access emergency heating vouchers and benefits to pay for food, clothing, and transport to medical appointments.
• Enabled the Hospital Discharge Service support workers to attend home visits, raise safeguarding concerns and secure clinical support, which has prevented crisis situations and loss of life.

Key learning points

• Mutual trust and respect between system partners is crucial to create an environment where all partners can provide challenge and design services that work for people and communities.
• Working with a diverse range of local voluntary sector partners provides insights which help partners to co-design care and support plans that meet local needs. This shared insight and contribution helps form a more effective system response to tackling immediate problems as well as creating long term solutions. 
• Taking a holistic family approach to health and care is important to ensure that care provided by unpaid carers can be sustained. Supporting unpaid carers is crucial in maintaining the health and care system.
• It is critical to look beyond the medical model of health when delivering effective person-centred care and discharge support. The wider determinants of health such as housing, environment and employment should also be considered when supporting patients and carers to remain well and at home. Providing practical support will reduce hospital admissions and ensure that patients get the help they need from the right service.

Find out more

You can watch a video case study about the Sefton Crisis Café below.