Staffordshire Housing Group, along with its dedicated partners, offer essential support to older individuals and vulnerable people with complex health conditions. They provide comprehensive assistance in areas such as health, housing, financial management, social engagement, and navigation services. This valuable support is provided promptly after these individuals are discharged from the hospital, ensuring their well-being is prioritised every step of the way.

1. How Housing Can Help People Be
Discharged From Hospital
Current Issues Faced In Discharging Patients From Hospital
NHS Central London CCG has recognised a concerning issue where patients, especially those
with complex health needs, have unfortunately slipped through the cracks between the realms
of health and social care. This gap in support has highlighted the urgent need for improved
coordination and seamless integration across these crucial sectors. Efficiently coordinating
social care and housing services, while incorporating step down/intermediate care programs
and accessible housing design, is key to minimising the delayed transfer of care. This not only
ensures timely discharge but also enhances patient outcomes. By prioritising these strategies,
we can create a seamless transition for patients and improve overall healthcare delivery.

2. The Quick Guide by NHS England called "Discharge to Assess" highlights the significance of
prompt assessments in which returning home is the preferred option. For those who are unable
to go home immediately, alternative pathways are available to ensure their needs are met
efficiently.
How Housing Can Assist
1. Coordination of services
Staffordshire Housing Group, along with its dedicated partners, offer essential support to older
individuals and vulnerable people with complex health conditions. They provide comprehensive
assistance in areas such as health, housing, financial management, social engagement, and
navigation services. This valuable support is provided promptly after these individuals are
discharged from the hospital, ensuring their well-being is prioritised every step of the way.
Thanks to the generous funding provided by Stoke-on-Trent CCG, this project has been able to
make a significant impact. According to the project evaluation conducted between July and
December 2014, an impressive 92% of service users did not require readmission to the hospital.
This highlights the effectiveness and success of our efforts in improving patient care and
outcomes.
The Home from Hospital Partnership in North Somerset is dedicated to supporting individuals
during their transition from hospital to home. Through meaningful conversations on various
topics such as housing, finances, social care, and social support, we ensure that people are
well-prepared for their discharge. Our aim is to provide practical assistance and guidance every
step of the way.
2. Provision Of Step Down Services
The Bradford Respite and Intermediate Care Support Services are dedicated to offering a
much-needed lifeline for individuals facing homelessness or residing in inadequate, insecure, or
perilous housing situations. In collaboration with Bradford City CCG, this valuable initiative
provides a step-down service aimed at helping these vulnerable individuals find suitable and
secure accommodation options. After a thorough evaluation, it was determined that the service
had a significant positive impact on length of stay rates. Clients were highly satisfied with the
experience, resulting in increased levels of client satisfaction all around.
The Curo Step Down scheme offers a crucial solution for vulnerable patients who are being
discharged from the hospital. By providing temporary accommodation, it ensures that these
individuals have a safe and secure place to transition back to their daily lives. This initiative
plays a vital role in promoting overall well-being and recovery for those in need. The project took
off in early 2014 and yielded impressive results.
Over 60% of clients were successfully discharged to locations outside of residential care,
showcasing the effectiveness of our approach. Additionally, we were able to assist an
impressive 79% of clients in forming valuable contracts with external services and groups,
further enhancing their support network.

3. At Tile House, we are committed to offering unwavering support to individuals facing mental
health challenges, including those with forensic histories. Our aim is to empower them to
transition from hospital and residential care settings and avoid the need for re-admission. We
understand the importance of a nurturing environment and work tirelessly to provide the
necessary assistance for individuals on their journey towards improved mental well-being.
The evaluation conducted in October 2014 clearly demonstrated the positive impact of the
service. It not only reduced the length of hospital stays for admissions but also prevented 23
instances of hospital visits altogether. This is a remarkable achievement that highlights the
effectiveness and value of this service.
3. Accessible Housing Design
The ASSIST Project in Mansfield is dedicated to ensuring that patients come back to a suitable
living environment after their hospital stay. They provide valuable assistance by making
adaptations, offering advice, and even helping individuals relocate to more suitable
accommodations if needed. Their commitment to patient well-being is commendable. ASSIST
has been proudly commissioned by the CCG as an indispensable component of the Better Care
Plan for Mid Nottinghamshire. Since its implementation in October 2014, it has successfully
assisted and supported a remarkable 1280 individuals. Furthermore, it is projected to deliver
substantial annual savings of £1.3 million.
Aspire is a remarkable national charity that offers a temporary housing solution for individuals
who have recently been discharged after experiencing spinal cord injuries. This invaluable
service ensures that they have a safe place to stay while awaiting more permanent housing
arrangements. Additionally, Aspire goes the extra mile by providing a free, dedicated housing
case management service. Through this service, they assist individuals with spinal cord injuries
in navigating the various housing challenges they may encounter. Aspire truly understands the
gravity of these issues and strives to make a positive impact on the lives of those in need.
Written by nowmedical