Home from Hospital Funds

Carers Hub
(Ncompass)

Hospital Discharge Project – Our idea is to increase identification of unpaid carers at the point of discharge from hospital and provide them with the support required to manage their caring role effectively at home. This may be the carer themselves who is being discharged, or more likely they will be caring for an older patient who is leaving hospital into a home environment.

By putting measures in place to support the carer to help ensure they have everything in place to support the person they care for in their home, and by helping them to continue in their caring role by aiding with their health and wellbeing, this will in turn take pressure off other services by decreasing contact with and reliance on GPs, Hospital and Social Care and decreasing risk of admission/readmission.

In partnership with Tracing Steps, this initiative will hold engaging and inclusive exercise classes at both Demesne Community Centre, and at care homes across the borough. Working with the Adult Social Care Team, this will target homes with fewer activities or higher levels of falls.

These classes have been thoughtfully crafted to improve mobility and combat feelings of isolation and loneliness for people aged 60 and above. The instructor, Tracey, has 20 years of experience working with a wide range of mobility and fragility, including an OCN in leading older people in dance and movement. She specialises in clients with low mobility, and in recovery from operations, as well as in regards to dementia, Parkinson’s and Multiple Sclerosis.

Working with the four ‘Cluster Hospitals’ of Rochdale Infirmary, North Manchester General, Royal Oldham and Fairfield, this project will offer home from hospital transport alongside a structured programme of 1:1 support at home or in community venues, built on each individual’s needs, alongside wider group support and social activities.

The team will build on existing relationships with discharge teams as well as working with Social Prescribing Link Workers to identify people recently discharged or at risk of readmission. HMR Circle works in partnership with Wai Yin Society, Caribbean and African Health Network (CAHN) and Care & Repair to provide culturally appropriate support.

The grant will expand the reach and impact of an existing program funded through the 10GM Hospital Discharge Pilot. The Prevention and Wellbeing Link Worker will offer in person support in a hospital setting prior to discharge, through the Petrus Hub and over the phone with a predominant focus on identifying and supporting individuals at risk of homelessness by:

• Assessing needs 
• Understanding barriers 
• Promoting MDT and multi-agency approach 
• Identify and link into established support networks 
• Act as a navigator to safely leave the hospital setting and build community-based support
• networks

This project will build on an existing Delayed Transfer of Care project working within mental health wards to address barriers to discharge in a holistic way. The approach has already had a demonstrable impact on the number of people with no reason to reside.

Increasing the capacity of the team will enable Mind to work with people over a longer timeframe including practical support, signposting and liaising with professionals and the wider VCFSE sector to support discharge.

RWWA will prevent hospital admissions through self-management education to help South Asian women with long-term conditions develop an understanding of how their condition affects their lives and how to cope with their symptoms. The service will address linguistic and cultural barriers by providing a multi-lingual prevention offer including:

• Bilingual counselling
• Art and walking therapies
• Gardening project
• Self-management programme to support with COPD, diabetes etc
• Wellbeing programmes to focus on anxiety, depression and panic attacks
• Mental Health Level 2 First Aider
• Social programme – including lunch club and meal on wheel
• Armchair Exercise
• Chia and Chat group therapy
• Health cooking club to focus on nutrition and healthy eating

The Stay Strong Stay Safe Project will create a sustainable prevention model to increase the health & wellbeing of older people through targeted exercise and education interventions for residents at care homes across the Rochdale Borough. Working in partnership with HMR Circle and a wide range of other organisations, it will not only help the residents at the care homes but also support their families and carers.

• Stay Strong Stay Safe consists of four key elements:
• Library of Online Exercises
• Masterclass Training
• Volunteer Network
• Supporting families and carers

This project will take the work of the Hospice to support people to self-manage their symptoms and bring it into the community, in settings close to home where people feel comfortable. The Hospice supports people at high risk of hospital admission due to living with a palliative life limiting condition, but there is lots that people can do around managing fatigue, anxiety, breathlessness, sleep, pain, falls prevention, nutrition and planning for the future.

A registered nurse, nursing assistant and creative therapist will host sessions in the community where people can receive advice and take part in relaxing, therapeutic and creative activities. These will give people new skills and coping strategies to improve their quality of life and keep them out of hospital.

Hospital discharge service: this service will be delivered in people’s homes and the community from the point of discharge for 6-8 weeks until both the beneficiary and our care assistant agree that the person is confident and well enough to continue to live independently without the support. Support to attend sessions at Deeplish Community Centre can be ongoing, for example wellbeing sessions or to see the local Imam if they are unable to attend their local mosque, as this can prevent future hospital admissions.

Prevention service: two half-day sessions per week from Deeplish Community Centre, including minibus transport to and from the Centre for those unable to travel independently. Each session will include a health check element. DCC staff are already trained to measure blood pressure, glucose and cholesterol. Health professionals will be invited to give talks on preventable diseases including stroke, heart disease and diabetes.

The prevention offer will also include culturally appropriate therapeutic activities delivered by mental health specialists in each session. This will include arts and crafts; storytelling; reading and music by groups such as Living Well, Rochdale MIND and Cartwheel Arts.

KYP will strengthen and build on their existing culturally appropriate day care service for BAME and marginalised communities, providing support to BAME communities to enable social connection, boost self-esteem and confidence, reduce isolation and loneliness, raise awareness of health issues, promote well-being and resilience in later life and generally help maintain a good, healthy lifestyle.

One male and one female community worker will provide multi-lingual culturally appropriate support around social connections, gentle exercise, wellbeing and health talks and screenings.

Caring and Sharing will set up a befriending project for people over 60, offering weekly phone calls and monthly social groups to create social connections, build confidence and increase resilience. The project will address barriers including language and accessibility, including offering transport and working with volunteers with different language skills, taking a holistic approach to meet each older person’s needs.