Supporting people to leave hospital

We aim to ensure fewer people stay in hospital longer than necessary and to divert people from hospital services whenever possible. We recognise, however, that hospital discharge is an area for further improvement and we have developed an action plan which sets out how we will work with our NHS partners around improvements to hospital discharge in the short and medium term.

Home First - Supported hospital discharge

Home First is a multi-agency approach which enables people to be discharged from hospital directly to their home when they are medically ready. The service is led by Sussex Community NHS Foundation Trust and is supported by social care professionals and care providers commissioned by the council. Home First supports people whilst assessments for longer-term health and/or social care services are undertaken in their home instead of in hospital. This service is constantly under review so that we manage seasonal demands and support as many people as possible to return home from hospital.

From April 2023 to March 2024, 4,827 referrals were made and 4,119 of these people remained at home after the service.

Combined Placement and Sourcing Team

Our Combined Placement and Sourcing Team runs a service which focuses on finding sustainable care solutions for people who need lifelong services and for people of working-age with mental health needs. The aim is to reduce the number of delayed hospital discharges, whilst also preventing admissions where possible, and to fully utilise block-booked and directly provided services. The team is proving highly effective in managing referrals making best use of our resources by accessing appropriate care and support for people at the right time.

‘Discharge to assess with reablement’ services    

‘Discharge to assess with reablement’ services are designed to support people to regain as much independence as possible after they leave hospital by providing reablement in a care home in the community, with 24-hour care and support available.  Social care workers, occupational therapists and care staff are on hand to assess any ongoing care and support needs and to provide assistance to enable people to return to their home wherever possible.

The service plays a key role in ensuring that people who are medically ready can be discharged from hospital and importantly, ensures that no long-term decisions concerning care and support needs are made in hospital.

In 2023-24,  170 individuals were discharged into social care reablement beds, and of these 57% returned to their own home.