As part of Hillingdon Health and Care Partners (HHCP) priorities for improving length of stay for patients at The Hillingdon Hospital, a significant need was identified for proactive and early support for patients under Neuro-Rehab care.
The Alderbourne & Daniel’s Rehabilitation Units support patients often dealing with wide-ranging, long-term neurological symptoms such as impairments to cognitive function, memory, speech, and physical mobility, which can affect everything from basic everyday tasks to future employment opportunities, financial stability, personal relationships and their ability to achieve life goals. This impact can be life changing.
Neuro-rehab patients are likely to experience physical regression, anxiety, loss of confidence, depression, poor diet and nutrition, cognitive decline, self-neglect, isolation, and loneliness. There is also the significant impact on the wider family and caring network.
Due to the complex nature of their condition(s) and the level of care and support that is needed in the community to support their needs, Neuro-rehab patients typically end up staying longer in hospital than is clinically required and/or have a high rate of readmittance to hospital due to their needs not being appropriately supported post discharge.
To better support this patient cohort, improve their transition from ward to home and reduce their need for readmissions, H4All working in partnership with our colleagues across the HHCP, have developed a pilot Neuro Wellbeing Support service.
The team (which consists of a part time Wellbeing Support Officer and a part time Information, Advice & Benefits officer) works alongside the existing multi-disciplinary team to support patients while they are on the wards and help them prepare for discharge.
The H4All team use a person-centred approach to help patients regain the skills, knowledge, and confidence to manage their long-term health needs (physical and mental), lead a better quality of life, redevelop social networks, address some of the wider determinants of health. They work holistically to support patients with their recovery and to reduce the risk of loneliness and isolation post discharge.
It is envisaged that this additional and alternative resource will:
· Provide earlier discharge planning as well as supporting patients during discharge to accelerate and improve the quality of - and their experience of - the discharge process
· Reduce patients’ length of stay
· Enhance patients’ quality of life
· Appropriately understand patients’ needs and goals
· Support, streamline, and improve these patients’ care
· Ensure patients have a positive experience of care
· Free up health resources to be able to provide additional support to patients in care
· Provide support for wider family, friends and/or carers
· Identify needs that potentially will reduce additional health and social care pressures
· Work as an integrated team to join up services that can leverage system and patient outcomes
We at H4All, along with our partners, believe that this approach will not only ensure continuity of care for these high need patients, but improve their patient journey and experience with a more expedient discharge process. Our hope is that, in turn it will reduce their length of stay/avoid delays in discharge and then further reduce their risk of readmission.
Professional testimony:
“The H4All team have been working hard behind the scenes to ensure that patient with life changing neurological injuries have a smooth transition back into the community when they are discharged from our inpatient neuro rehab wards. Sally and Gena have a wealth of practical information and ensured our patients felt supported in their hour of need.”
– Dr Ajoy Nair
Patient testimony:
“I wouldn’t have known about all the Services and help available to me and my husband without H4All. I am really happy with the Service and the help I received both on the ward and at home after my discharge”
– Fatima Fernandes.
“The information and support me and my family have received from H4All has definitely made a difference and given me peace of mind whilst I continue with my rehabilitation.”
– Ronald Hearne.
A word from one of the Neuro Wellbeing Support Team:
“I am very happy to support people who have suffered a life changing illness and their families in navigating through the many services out there that can support them. Many have no idea what’s available and this can be very daunting along with coming to terms with their illness and facing challenges they were not expecting resulting in a change of lifestyle. Gaining the support they need enables them to still have choice and control over their daily lives.”
– Sally Spring, Neuro Rehab Wellbeing Officer
The Integrated team working with Hillingdon Neuro Rehab Patients:
*Left to right (L-R)
Standing L-R: Jadzia Duncan-Bosu, Eleanor Loudon, Raj Seepersad, Ajoy Nair, Sally, Nelson Debbie Clark
Sitting L-R: Sukhi, Bianca Holthuis, Courtney, Helen Johnston