Take Home and Settle Service (THAS)

• Improve the quality of discharges for patients identified by the hospital teams as vulnerable and isolated due to having no home support system. The service will ensure that the patient's home environment is safe and heated that there is food in the house appropriate for their cultural, religious or dietary needs, and that the patient feels confident in their ability to manage at home.
• There is follow up via a telephone call the following day or follow up visit, if required, when a telephone call is not an option or there are other communication barriers or a call remains unanswered, , to ensure that the person taken home is managing well on their own. If they are not, a referral is made to other services including adult social care services.
• Reduced readmissions - Take Home & Settle services provided locally have evidenced that only 2% of patients who benefit from the 'take home and settle' service are readmitted to hospital 30 days after discharge.
• Improve the confidence of patients and their families when being discharged home from hospital

Reporting:

The service will report monthly on the following:

• Number of referrals to the service from each LGT site & community site
• Date & source of referral (Site, Ward and /or other)
• Time of day / day of week provided
• Response time (target 30 minutes)
• Whether referrals are accepted / completed or cancelled
• Details of other support offered / reasons why referrals have not been completed or cancelled
• Number of items of equipment delivered from UHL
• Promotion activity

The service will also provide a quarterly report including the following:

• Summary of activity during quarter & any issues impacting positively or negatively on service delivery
• Readmission rates of patients supported (where data is available from LGT)
• Case Study reflecting outcomes from THAS service
• Patient feedback (including feedback from carers)
• Demographic summary of patients using the service showing age, gender and ethnicity

Service targets:

• Target for THAS is 50 patients per month for each Lewisham and 40 patients for Greenwich(based on previous years data borough,
• Response time from referral: 30 minutes
• Patient feedback is 80% good or excellent
• Increase in number of patients collected during morning shift noting that this is dependent on times of discharge which are not within the service's control
• Increase use of THAS during weekends noting that this is dependent on times of discharge which are not within the service's control
• Proportion of referrals completed: 85%
• Proportion of referrals where the Provider was responsible for non-completion of the referral: 10%

The Provider will continue to promote THAS across the relevant hospital and community sites, particularly targeting the 9-1 and weekend shifts to encourage the number of referrals made during these times.