Recovery at home - support for elderly patients in their own homes

Recovery at home - support for elderly patients in their own homes

Elderly patients who’ve had a spell in hospital are being supported to return home to continue their recovery, under a new scheme being piloted in North Herts, Welwyn and Hatfield and Stevenage.

The ‘Discharge Home to Assess’ service, launched at the end of November, is already proving popular with patients.

Those benefitting from the scheme are patients who are well enough to be discharged from hospital, but require extra help and support to complete their recovery.  For example, someone who has had a fall might need physiotherapy in their home, some help to keep up with cleaning and cooking and a regular visit from a community nurse.

Doctor Hari Pathmanathan, a Hertfordshire GP and Chair of East and North Hertfordshire Clinical Commissioning Group, said:

“We know that a prolonged hospital stay can result in a loss of confidence and muscle wastage, particularly when a patient is elderly or frail.  We are at the early stages of this scheme, but it seems that when people are back at home, in their familiar environments, they recover more quickly.”

Dr Elizabeth Kendrick, clinical lead for the project, says that people are delighted to be able to leave hospital earlier than they had thought possible, with the right care on offer:

“Over the three week period after leaving hospital, we have found that the amount of care patients need substantially reduces.  Some people have been able to return to completely independent living.”

The decision to allow patients to go home is taken by the discharge home to assess team, which includes representatives from the hospital discharge team and the care agency which will support them.  They are generally frail and/or elderly and well enough to manage alone at home overnight.  

Patients’ individual needs are assessed in their own home - rather than a hospital - under the care of their own GP, supported by a team of health and care experts which includes:

  • a GP with a special interest in frailty
  • community nurses
  • therapists
  • social workers
  • mental health practitioners
  • home care organisations and voluntary organisations


Note to editor:

The pilot is operating seven days a week, from 8am-8pm. It started on 29 November.

The service can support up to 20 patients at a time, with each patient expected to need support for up to 21 days.