PRJ-1286: Take Home and Settle service and Handyperson service

The main aim of the Take Home and Settle Service is to safely support patients’ discharge from hospital. Short term support is provided in the person’s home or other interim accommodation in order to support independence and prevent readmission to hospital. The service will enable individuals to regain confidence, motivation and skills to self-manage, and encourages them to engage with the local community to improve socialisation and wellbeing.

The service will provide 7-day support, working closely with health and social care to deliver integrated and co-ordinated care to adults. Service recipients will be registered with a C&H or Tower Hamlets GP and/or residing in these Boroughs who have been admitted to or are at risk of admission to the following hospitals:

• Homerton Healthcare NHS Foundation Trust
• Royal London Hospital (Bart's Health NHS Trust)

Patients at other hospitals out of borough but who live within Hackney or Tower Hamlets may also be referred to the service through our local discharge/transfer of care hubs. These will be a small number of the overall eligible residents.

The key aims of this service will be to:

• Prevent unnecessary admissions through A&E
• Proactively engage with Ward and Discharge Teams to facilitate early, safe and sustainable discharge reducing length of stay and delayed transfers of care from the hospitals listed above
• Reduce avoidable re-admissions over the short period following discharge period
• Work closely with health and social care services to improve patient experience
• Signpost and refer to community services and support with the aim of enabling patients to remain independent at home wherever possible.