Jordan Johnson, Wellbeing Services and Operations Manager at Warrington Voluntary Action, explains how integrating link workers with hospital discharge teams has supported people suffering from health inequalities and reduced readmissions.
Key lessons from this case study
- Integration of Voluntary, Community and Social Enterprise (VCSE) link workers within hospital teams to foster strong partnerships and understanding of the benefits they can bring.
- Recognition the value of the VCSE sector in coordinating support in acute settings and channelling resources towards secondary prevention.
- Continuously monitoring and analysing referrals and outcomes to make informed adjustments to the service delivery model.
- Proactively engaging with both patients and the multi-disciplinary team to identify and explain benefits of the service.
- Retain flexibility in service delivery to adapt to challenges and changes
The issues we wanted to address
The Voluntary, Community & Social Enterprise (VCSE) Sector has a key role to play in supporting hospital discharge pathways, specifically pathways 1 to 3 where the patient has new health or social care needs, or is moving to a new residence. VCSE organisations are uniquely placed to support people and communities and are vitally important to reducing hospital readmissions, recovery planning, supporting population health and reducing health inequalities.
We identified that these benefits were being missed in the discharge process. Most clinical staff were not aware of service offered by the VCSE, and most certainly didn't have the time to research the local offer. Fully embedding the VCSE within discharge pathways would provide a more effective flow and ensure peopleās non-clinical needs were on par with their clinical needs.
The aim of a new initiative was to provide better patient choice, better patient outcomes, smoother pathways, reduced hospital stays and lower overall costs.
What we did and how
A two-year pilot project gained funding from NHS Charities Together as part of a strategic bid by Cheshire and Merseyside Integrated Care Board.
The Healthy & Home service was developed by Warrington Voluntary Action (WVA). It is delivered through 2.5 FTE Link Workers, employed by WVA, who are integrated within Warrington Hospitalās discharge team, with access to health IT systems and data. The model ensures that the VCSE is fully involved in the discharge process, as a valued and trusted partner in the multi-disciplinary team arranging packages of support for patients going home.
The Healthy & Home team take referrals for patients who are due to be discharged from hospital and are in one of our target groups:
- Elderly or frail and in need of support to return to their own home
- Suffering from chronic conditions including Long Covid
- Living in deprived wards of Warrington and Halton
- From āhidden communitiesā: people with a learning disability, people who experience difficulties with their mental health, people who have drug and alcohol issues, and those suffering from domestic violence.
The Link Workers visit patients on the ward. A support plan is completed with the patient to identify their goals, their existing networks of support, and areas they need or would like more support with. Referrals are then made to relevant VCSE organisations and followed up if required.
The service provides a triage point for volunteer support and a network of specialist VCSE services and community connections, acting as a āfront door to the VCSEā. This helps reticent patients feel much more comfortable about being discharged.
Following discharge, welfare calls are made to the patients to ensure they feel sufficiently supported. These calls are continued for up to 12 weeks or until the patient advises they are no longer required.
Our challenges and how we overcame them
In essence, our biggest challenge lay in the need to shift from a passive referral expectation to a proactive engagement model. In the early stages, our expectation that referrals would naturally flow from the discharge team or through word-of-mouth within the hospital proved unsuccessful, leading to low referral rates during the initial months of the project.
Our VCSE Link Workers recognised the need for a more hands-on approach. They began attending daily "Right to Reside" meetings, identifying eligible patients and visiting these patients on the wards, engaging with them personally to discuss the offerings of Healthy & Home and assess if any additional support was required.
The link workers established a daily rota, ensuring coverage of all wards throughout the week. By actively participating in ward round meetings, they seized the opportunity to promote the Healthy & Home service directly to hospital staff, fostering awareness of the support available. This concerted effort not only increased visibility but also significantly boosted the caseload, ensuring that more individuals were reached and connected with the necessary support before leaving the hospital.
Results
The results achieved by Healthy & Home over the past two years demonstrate a substantial positive impact on both patient outcomes and potential financial savings. In the first year of implementation, the service received 871 referrals, rising to 1763 referrals in the second year.
One of the most notable indicators of success is the significant reduction in hospital readmissions. Healthy & Home reported that 81% of individuals accessing the service did not reappear in the hospital within a 12-month snapshot. This highlights the efficacy of the service in preventing the recurrence of health issues.
In terms of potential cost savings, the service has proven to be financially prudent, due to reducing both the number of times urgent care is accessed and the level of investigation required when it is. For patients in discharge pathways 0-2 (ie excluding care home settings), minimum cost savings in a 12-month snapshot were calculated at Ā£321,880.
Individual Case Study:
Nick* (*not his real name) was suffering from Long Covid, which led to a āmini strokeā and further health problems. In turn this led to him being let go from the job he loved doing. He found himself housebound, with severe arthritis in his knees and restricted to the bottom floor of his house.
Nick got referred into Healthy & Home by his Occupational Therapist as he was keen to improve his quality of life. When the Healthy and Home Link worker spoke with him, he discussed previously having numerous hobbies and interests but due to his condition he hadnāt pursued any of them for a long time. He required support to go out and about and meet people again, and he also wanted support to aid his mobility to utilise the upstairs of his home again, so he could go on his computer and sleep in his own room.
Healthy & Home linked Nick with three different organisations to help him achieve what he wanted to do. As he is unable to work, the cost of living has significantly affected him both financially and mentally.Ā Citizens Advice were able to go through his benefit entitlements with him, and supported him to make the necessary applications, leading to a significant increase in his monthly income.
The second referral was to Warrington Disability Partnership, who were able to explore with him how to install a lift in his property. Following a successful application to the Steve Morgan Foundation for a grant, he is now able to access his upstairs rooms again.
The final referral went to Good Neighbours. Nick was very keen to get out and about in his local community but lacked the confidence to do this. Good Neighbours were able to link him with a volunteer, who accompanied him on weekly visits to a community cafĆ©. During their visits the volunteer encouraged conversations between Nick and other regulars of the cafĆ© and in turn he was able to start building a new friendship group that he felt confident seeing without the volunteerās support.
What's next?
Partners remained committed to the success of Healthy & Home. Since the end of the pilot its continuation is being funded by Cheshire and Merseyside ICBās Site Specific Group funding, with a permanent funding stream and expansion and enhancement of the service under discussion.
We remain committed to ongoing evaluation to demonstrate the impact and value of the service, and responsiveness to the dynamic healthcare environment to further elevate its effectiveness. This strategic combination positions us to continue making a meaningful impact on patient outcomes and community well-being.
You can find out more about the Healthy & Home service with this video. Ā
