Community support to get people home from hospital

What’s needed and what helps

What helps people avoid the need for hospital care, or get home quickly and easily if they do need to go? Part of the answer is community support, and a wider range of practical supports than many people might expect.

Sign up for our Conversation Starter event to explore recent learning and ideas about this topic.

Learning from Pembrokeshire in Wales

We’ve been working with partners in Pembrokeshire who have developed the PIVOT project, which is designed to co-ordinate that community support.  It includes a community service that gives help to people in their own homes, to help them stay well and avoid the need for in-patient care.  Part of that is working alongside services like Care and Repair – those small improvements like a grab rail that helps prevent falls and give people confidence.

When people are at hospital, such as a clinic appointment or at A&E, they want to get home if possible.  But if you live a distance away in a rural area with no public transport in the evening, that can mean a hospital admission. This might initially just be overnight, but then things can get more complicated. The solution in PIVOT is volunteer drivers who will take people home and see they are ok.  The community transport service is one of the partners whose support links into short-term volunteer community support, which links to other services if someone needs them.

The support also works alongside local health and social care staff, and each services knows how to make referrals or point people towards the others.  The teams work together and have simplified things like complicated assessment processes for smaller amounts of support or low-cost practical items – the processes that slow things down and take up staff time in many other places.

Making community support around transport work

Many other places in Scotland and Wales, and the rest of the UK, have some of these community supports. But they’re not in each area, or missing one of the key parts, or not joining up. Or they’re only accessible through a process that creates delay and limits the flexible response to what people need.  The good news is that in some places people are working on ways to get people home from hospital. This will help folk with lower needs and when people need more support that can also be delivered better in the community.

People in Pembrokeshire point out that all this has happened because there is a culture of trust and partnership between the public and voluntary sectors.  That has been nurtured and planned too, with liaison posts in the third sector and now also the NHS.  This is part of a strong focus on prevention, planning how to fill gaps anyone spots, and making the day-to-day working as smooth and productive as possible.

Conversation starter

Outside the Box and our partners in the Rural Wisdom project are hosting one of our Conversation Starters on 9th November, to share the example of work in Pembrokeshire. It’s for anyone interested in how this works and how to use the ideas and experience to make things better in your communities. We hope you will join us!

Sign up for our transport support Conversation Starter on Eventbrite. 

And if you know of other places that are managing to link up all the community supports to work easily and well for people living there, let us know. We’d love to hear about it and hope you will share these examples too.