1) The document describes a case study of Mr. JR, an 81-year-old man living alone in housing association property who was admitted to the hospital twice due to an unsafe discharge home because of hoarding and unsafe living conditions in his home. 2) After being seen by the Health & Housing Discharge Coordinator, Mr. JR's home underwent clutter clearance, deep cleaning, and he was connected to support services for ongoing cleaning assistance and decluttering support. 3) The risks of falls, injury, loss of independence, social isolation, and homelessness were reduced, and in a follow-up visit Mr. JR reported being happier in his cleaner home without falls since discharge

1. DFG Champions Roadshow
Health & Housing Discharge Coordinator
West Kent Collaboration
Pembury Acute Hospital – Tunbridge Wells
Janice Greenwood - Tunbridge Wells Borough Council
Danielle Shurgold – Family Mosaic
Linda Hibbs – Tonbridge & Malling Borough Council

2. Recognition of importance of Housing to good Health
and Wellbeing - 2017-2019 Integration and BCF

3. I just want to go home…

4. Do something different?

5. Develop a pilot service?

6. The Health & Housing
Coordinator role

7. Case Study Mr JR
• Mr JR, 81 year old male living alone in housing association property,
hoarder, not willing to engage with landlord or community as fearful of
losing tenancy due to state of property. Admitted 22nd Jan 17 referred to
and seen by me on 2nd Feb 17.
• Mr JR was re-admitted to Tunbridge Wells Hospital due to an initial unsafe
discharge home. Patient transport took Mr JR home and then re-admitted
him due to the condition of his home environment and unsafe living
conditions.
• Mr JR reported that he spends most of his time sitting in his arm chair
reading, he does not have a cleaner or any support. Mr JR thought his
home had got into the condition it was in due to the council not collecting
his newspapers and so the house has just got messier as time has gone by.
• On visiting the property I found that each room was cluttered with
possessions. Each room was very dirty and the bedroom had yoghurt pots
filled with urine in. Access was not possible by mobility frame to any of
the rooms due to clutter.

8. • Handymen clutter clearance to enable safe access to all rooms
(HHC budget)
• Deep clean in kitchen, bathroom, bedroom and flooring (Patient
funded)
Immediately identified

9. Secondary needs
• AGE UK for shopping and cleaning assistance on going. (Patient funded)
• Good neighbour service for on-going de cluttering and be-friending.
(Voluntary service)
• Occupational Therapy for bed and bathing transfers.

10. Risks reduced
• Falls and injury to patient and
carers.
• Loss of independence in
accessing bathing and bed.
• Social isolation.
• Environment/health.
• Homelessness/losing tenancy
(Housing Association
discovering property in the
state it was.)

11. Aftercare
• Post discharge visit completed and Mr JR reported
he is feeling a lot happier in his home and is
working on the ongoing clutter removal daily. Mr JR
reported no falls since discharge. I noticed a
significant difference in the amount of clutter in
each room and the cleanliness of the property was
still as clean as when he discharged from hospital.

12. Overcoming issues

13. What is different?

14. Aspirations

15. Housing at the centre…

16. Deconditioning!!!
• 65% of elderly patients become deconditioned after
2 days of hospitalisation
• 67% failed to improve before discharge
• 10% deteriorated further

17. What we know, savings so far…
£30,017.52

18. Thank you and good luck