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Integrated Care

Hospital to Home Services

My Care My Home provides an enhanced service that strives to deliver a truly integrated provision through collaborative working and joined up delivery.

Securing individuals back into their local community is a crucial part of the Hospital to Home Service whether there is a requirement for a low level support package, reablement or end of life care.

When individuals are discharged from hospital they may require intensive support to help them get back on their feet.

What will be achieved through this programme?

The Hospital to Home service can open up a pathway for all patients self-presenting at the local hospital or arriving by ambulance at their local A&E department, where they are assessed as medically safe to return home.

The patient can then be discharged home with an appropriate care package from My Care My Home and be cared for and supported until services can be put in place by the local authority or, if self funding, a provider can be found to supply a private service to the patient that meets their own required needs.

What does the service offer?

  • No patient is in hospital longer then required
  • No patient is admitted to an acute hospital for non-medical reasons
  • The patient is able to go home to their normal place of residence which is a key priority
  • There is a reduction in the amount of delayed transfers of care
  • Rapid Discharge – Patients can be discharged safely within 48 hours of referral to MCMH
  • Integration with Health and Social Services at the point of need
  • Clear pathways of joint working across health and social care
  • 7 Day discharge service
  • Aftercare services

What are the overall benefits?

This service prevents a significant number of admissions, and increases timely discharge from hospital thus reducing unnecessary prolonged stays in hospital.

At any one time there are a number of people in an acute bed, whose medical episode is complete, but are unable to manage without support at home or in a residential setting. Rather than wait in hospital for a further assessment of their long term care needs or for the setting up of an appropriate package of care, the home from hospital service can ensure the delivery of a high quality and responsive service that speeds up discharge times or prevents inappropriate hospital admissions and improves outcomes for individuals with additional care needs.

Elements of Support

  • Low level support
  • Reablement
  • End of Life Care

For further information on this service please contact Joanne Davies.

Telephone 029 2036 5591
Freephone 0800 731 8470
Email: joanne.davies@mycaremyhome.co.uk