Hospital to Home
Housing Strategy Team in partnership
with Brighter Futures
Developed in partnership with:
Overview………
12 month pilot running until August 2014
All Tenures of Housing
Anyone over the age of 18
Physical and Mental Health
Objectives……
Hospital discharge is not delayed due to housing
issues
Inpatient stays are shorter
Emergency admissions are decreased due to
Housing Conditions
Enabling options to allow people to remain in
their own home and live independently and to
avert crisis situations
Referral
Where homelessness or unsuitable housing is
identified as a barrier to discharge a referral can be
made by Ward Staff or the Discharge Service.
Health or Social Care professionals can refer in where
a housing issue is identified that is having a negative
impact on someone’s health.
Hospital Link Project
Hospital Link Project
Introduction to Brighter Futures
Staff on Hospital Link Project
Fabio Rendina – Complex Needs Worker
Ben Wilson – Complex Needs Worker
Hospital Link Project
The Service
Brighter Futures have been commissioned to work
along side Tamworth Borough Council for 6
months to provide the pilot which is an extension
of the current ‘Hospital to Home’ project. The
pilot aims to work with 15 customers with
complex needs in the time frame.
Hospital Link Project
the role of the team
•
To proved a package of support for
customers with complex needs who are
currently inpatients at hospital due to
homelessness. The service will provide ongoing support after discharge to ensure
customers remain housed and prevent readmission.
Hospital Link Project
What are Complex Needs?
People with complex needs will have experienced some
of the following trigger factors:
Physical ill health, Mental ill health
Bereavement
Undiagnosed Learning disability
Sexual abuse or exploitation.
Physical or psychological abuse.
Poor Support, inadequate housing
Hospital Link Project
What are Complex Needs?
Customers who suffer from one or more of the above trigger factors, often
use Self help treatments which include:
Using alcohol or illegal drugs.
Unhealthy use of religious or spiritual ideologies.
Joining gangs, institutions or extremist organisations.
Addictive or unnecessary pursuit of money, power or sex.
Offending, offensive or anti‐social behaviour
Self doubt self harm or self punishment.
Seeking social isolation.
Becoming over dependent on service
Becoming pregnant
Hospital Link Project
What are Complex Needs? (continued)
We provide effective solutions for Complex Needs by providing an Individually designed package
of support which provides an appropriate alternative mode of coping with the underlying pain
which does not involve the use of self help treatments.
Designed to remove the underlying causes of the predisposing conditions where possible.
Designed collaboratively, after discussion, negotiation and with the agreement of the customer.
Holistic: they address all the needs, physical and psychological of the customer.
Multi dimensional: they use all the many services of BRIGHTER FUTURES itself and also refer
customers to our many partners.
SMART, that is, specific (activities or targets), measurable (we include and measure frequency of
attendance etc), achievable (they are suited to the customer, not us), realistic (challenging, but
possible) and timely (they are offered in the right sequence).
Simple: these are understandable and legible pathways.
Hospital Link Project
Tools to support customers with Complex Needs
Assessment and Chaos Index
The Outcome Star – explanation of the 10
sections and score system.
Motivational Interviewing.
Hospital Link Project
Examples of customers who
could be referred to the
project?
Hospital Link Project
Referral Routes
Referral received from The Good Hope Hospital will go
directly to Alison Knight and an assessment carried
completed. Alison will then sign post or refer to brighter
Futures if appropriate.
Brighter Futures take direct referrals from George Bryant.
Housing Advice can refer direct to brighter Futures in an
emergency
Hospital Link Project
Questions?
