Changing the way health and social care is delivered is perhaps a tall order, but this much debated topic is being 
delivered by Hilton Nursing Partners, providing integrated care and support to transform patient wellbeing and recovery.
In partnership with the NHS, and local county councils, we are relieving the ever increasing pressure placed on the NHS and social care services with our nurse led Home to Decide™ service aimed at reducing residential care admissions for patients assessed for requiring residential care whilst in an acute hospital setting.
Underestimating the patient’s physical and mental capabilities to return home, patients’ remain in hospital waiting to be transferred into available residential care beds. The difficulty with the transfer model is it requires patients to remain in a state of limbo in a hospital bed as a DTOC’s (Delayed Transfer of Care) until space becomes available.
The negative effects can be far more concerning. Any lengthy stay in a bed is proven to result in muscle wastage, but the psychological effects of not being in your own environment can result in loss of confidence and potentially create a greater level of dependency.
A lengthy stay in hospital tends to result in further deterioration in patients’ health and fitness, a loss of confidence and a decline in emotional wellbeing. They may then present as unable to return to independent living and be assessed as requiring residential care or a community bed for a period of rehabilitation.
In these circumstances, patients will have little or no opportunity to consider their on-going situation and will often have no opportunity to return home to make arrangements prior to the move into residential care. Our aim has always been to help patients avoid a potentially stressful and distressing situation by providing the option to rehabilitate at home, which provides time to come to terms emotionally with their long-term needs.
Our Home to Decide™ philosophy of thinking was designed with a number of guiding principles:
a) Patients who prefer to live independently at home after an acute hospital stay should be supported to achieve this.
b) Patients need integrated health and social care that recognises the patient’s physical, emotional and social wellbeing
c) Patients are better served by support and encouragement that fosters independence.
d) Patient assessments undertaken must be of the highest quality to provide realistic expectations of outcomes.
e) A move into residential care is a major life decision for the patient and their family, support and emotional space to come to terms with these next steps are paramount.
f) Family members, neighbours and community organisations can all have a key role in maintaining a patient’s wellbeing and independence.
The model integrates health and social care, and draws upon Nurses, Occupational Therapists and Personal Nursing Assistants (PNAs highly trained healthcare assistants) to deliver an intensive programme of holistic support and assessment delivered in the patients’ own home.
Having successfully piloted and tested the Home to Decide™ model of care with NHS Trusts and Councils across the South East the results have been self-evident. The vast majority of patients were able to remain at home and continue to live independently with further benefits resulting in:
- Reduction in acute hospital DTOC days
- Provides patient choice and control regarding next steps
- Reduction in residential care placements commissioned
- Better health outcomes as a result of patients living independently
- Reduction in annual social care costs of up to £20,000 per patient a year.
