Hospital to Home - Tamworth Borough Council

January 6, 2018 | Author: Anonymous | Category: Science, Health Science, Mental Health
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Description

Hospital to Home

Housing Strategy Team in partnership with Brighter Futures

Developed in partnership with:

Overview……… 

12 month pilot running until August 2014



All Tenures of Housing



Anyone over the age of 18



Physical and Mental Health

Objectives……  

 

Hospital discharge is not delayed due to housing issues Inpatient stays are shorter Emergency admissions are decreased due to Housing Conditions Enabling options to allow people to remain in their own home and live independently and to avert crisis situations

Referral 



Where homelessness or unsuitable housing is identified as a barrier to discharge a referral can be made by Ward Staff or the Discharge Service. Health or Social Care professionals can refer in where a housing issue is identified that is having a negative impact on someone’s health.

Hospital Link Project

Hospital Link Project Introduction to Brighter Futures Staff on Hospital Link Project  Fabio Rendina – Complex Needs Worker  Ben Wilson – Complex Needs Worker

Hospital Link Project 

The Service

Brighter Futures have been commissioned to work along side Tamworth Borough Council for 6 months to provide the pilot which is an extension of the current ‘Hospital to Home’ project. The pilot aims to work with 15 customers with complex needs in the time frame.

Hospital Link Project the role of the team •

To proved a package of support for customers with complex needs who are currently inpatients at hospital due to homelessness. The service will provide ongoing support after discharge to ensure customers remain housed and prevent readmission.

Hospital Link Project 

What are Complex Needs?



People with complex needs will have experienced some of the following trigger factors: Physical ill health, Mental ill health Bereavement Undiagnosed Learning disability Sexual abuse or exploitation. Physical or psychological abuse. Poor Support, inadequate housing

     

Hospital Link Project 

What are Complex Needs?



Customers who suffer from one or more of the above trigger factors, often use Self help treatments which include:



Using alcohol or illegal drugs. Unhealthy use of religious or spiritual ideologies. Joining gangs, institutions or extremist organisations. Addictive or unnecessary pursuit of money, power or sex. Offending, offensive or anti‐social behaviour Self doubt self harm or self punishment. Seeking social isolation. Becoming over dependent on service Becoming pregnant

       

Hospital Link Project 

What are Complex Needs? (continued)

We provide effective solutions for Complex Needs by providing an Individually designed package of support which provides an appropriate alternative mode of coping with the underlying pain which does not involve the use of self help treatments.  Designed to remove the underlying causes of the predisposing conditions where possible.  Designed collaboratively, after discussion, negotiation and with the agreement of the customer.  Holistic: they address all the needs, physical and psychological of the customer.  Multi dimensional: they use all the many services of BRIGHTER FUTURES itself and also refer customers to our many partners.  SMART, that is, specific (activities or targets), measurable (we include and measure frequency of  attendance etc), achievable (they are suited to the customer, not us), realistic (challenging, but  possible) and timely (they are offered in the right sequence).  Simple: these are understandable and legible pathways. 

Hospital Link Project 

Tools to support customers with Complex Needs



Assessment and Chaos Index



The Outcome Star – explanation of the 10 sections and score system.



Motivational Interviewing.

Hospital Link Project

Examples of customers who could be referred to the project?

Hospital Link Project Referral Routes 

Referral received from The Good Hope Hospital will go directly to Alison Knight and an assessment carried completed. Alison will then sign post or refer to brighter Futures if appropriate.



Brighter Futures take direct referrals from George Bryant.



Housing Advice can refer direct to brighter Futures in an emergency

Hospital Link Project

Questions?

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