Partnership case study: ‘Hospital to Home’ by Nottingham City Homes

This is a partnership project between Nottingham City Homes and Nottingham City Care Partnership.

Its aim is to ease the strain on the health service by:

  • providing suitable homes to speed up a patient’s discharge from hospital
  • directing people that are at risk of being admitted to hospital due to their poor living conditions into good quality homes.

Our challenge

‘Hospital to Home’ is a service aimed at improving links between housing and health in Nottingham. The service is only for people aged 60 or over (or 55 and over if on Disability Living Allowance or Personal Independence Payment). It includes two specific Housing Health Co-ordinator roles.

It is anecdotally believed that there is a demand for older people’s housing, many of whom are currently living in inappropriate accommodation which is negatively impacting upon their health and wellbeing. The Integrated Care Services have clients who would benefit from more appropriate housing, and Nottingham City Homes Homes have vacant properties that are fit for habitation and ready for immediate use. In that sense, it is a perfect partnership of need and resources.

Our solution                    

Housing & Health Coordinator roles have been introduced as part of a 12 month pilot scheme between Nottingham City Homes and Nottingham CityCare Partnership. They will improve the links between housing and health services in Nottingham City, helping more people to live in warm, comfortable and healthy homes. The coordinators serve as a referral point and additional resource to help source suitable accommodation to enable patients to be discharged from hospital and reduce readmissions.

An early estimate of cost savings shows an average saving to the NHS of £3,623 per patient. The feedback we have received from service users and their families is extremely positive.

Our impact

The scheme will be evaluated against NHS, Public Health and Social Care outcomes.

The planned evaluation will measure the financial impact (cost-benefit to the NHS and the housing provider) and social impact (client and carer wellbeing).

The outcomes will be assessed using a range of sources including:

  • project data on length of stay in NHS care during the rehousing process (compared to average duration)
  • information sharing on hospital admissions data (admissions, duration and re-admissions)
  • client and carer health and wellbeing surveys (including EQ-5D and Short Warwick-Edinburgh Mental Wellbeing Scale)

An early estimate of cost savings shows an average saving to the NHS of £3,623 per case, from reducing the length of stay in NHS facilities during the rehousing process.

Our Partnerships

The NHS Integrated Care services have clients who would benefit from such housing and by having a role dedicated to considering housing in care delivery there are other benefits to patients in addition to the delivery of more seamless care.

Nottingham City Homes also administer the HomeLink Partnership (a group of major Registered Providers in Nottingham) so will be able to direct clients to all providers of social housing in the city to help meet their housing needs.

Nottingham City Homes also have a Nottingham On Call service, Independent Living Co-ordinators and are responsible for the Telecare/telehealth alarm installations.

Our role

Housing services in this partnership project are able to:

  • reduce the risk of citizens ‘falling between the gaps’ on discharge from hospital
  • reduce the length of stay and bed blocking costs within NHS care
  • reduce admissions to hospital (patients are more likely to remain at home for longer if their environment is conducive to healthy living)
  • support tenants with debt advice, benefit claims, repairs and house moves.  This will consequently decrease clinical input time and increase patient facing time – clinicians often spend time supporting citizens with this advice
  • support the self-care agenda  and reduce social isolation by linking into the Independent Living Service of Nottingham City Homes, and use of community activity involvement

Our contribution to improving health

The objectives of the scheme are to:

  • support the tenant’s transition from a reablement bed to self-care or supported living at home
  • facilitate earlier discharge from hospital where inappropriate housing is the delaying factor in discharge
  • provide early intervention to support people whose health is negatively impacted by poor or inappropriate housing

The strategic outcomes are to:

  • improve the health and wellbeing of tenants who are negatively impacted by poor or inappropriate housing
  • enable people to live independently for longer, with less reliance on intensive care packages

The scheme aims to contribute to:

NHS OF

  • Domain 2 – Enhancing quality of life for people with long-term conditions
  • Domain 3 – Helping people to recover from episodes of ill-health or following injury.

PH OF

  • Wider determinants of health (fuel poverty, social isolation, community safety)
  • Health improvement (mental wellbeing, injuries due to falls)
  • Healthcare and premature mortality (HRQoL, emergency readmissions)

ASCOF:

  • All 4 domains