1. HEALTH AND WELLBEING BOARD STRATEGIC WORKSHOP 29 TH APRIL 2015 ASSIST HOSPITAL DISCHARGE SCHEME

2. 1.Remodelled the former Tenancy Support and Sheltered Housing Support Teams in response to reduced funding from Supporting People Fund 2.April 2013 Mansfield District Council launched a new service, ASSIST 3.Proactive service providing a wrap around tenancy support package to vulnerable tenants in both private and social housing

3. Advocacy, Sustainment, Support Independence and Safeguarding Team (ASSIST) Three elements:- The response service – 24 hour emergency response The response and support service – planned home visits, lifeline 24 hour monitoring service, homeless advice and support and handyman service The enhanced support service – help with housekeeping, escort to appointments, help with reading and companionship

4. Potential of the service quickly realised Promoted widely its existence across public sector partners in particular Health and Social Care ASSIST team member took part in KMH The Perfect Week, September 2014 to test elements of the Mid Notts Systems Resilience Plan

5. CCG commissioned ASSIST to pilot a Hospital Discharge Scheme in October 2014 as part of Better Care Fund Plan Aims:- to prevent homelessness, support tenancy sustainment, reduce and prevent admissions to residential care or hospital and expedite discharge

6. ACTIVITY:- deploys a wide range of housing and support services from one point of access relieves pressure on staff when a patient needs wrap around services to expedite change from hospital to residential care expanded to provide presence at A & E front door to provide support to people at A & E door who have social problems and issues rather than clinical

7. ACTIVITY (2) Since October AHDS has dealt with 300 clients undertaking an initial assessment leading to a number of interventions including: Installation of lifeline and assistive detectors e.g. fall detectors Key safe Meal preparation, domicilary support Support to attend GP/hospital Help with debt and welfare issues Safeguarding Support to families to resolve complex issues

8. Cost:- £49,000 – 6 months Initially 2 staff to cover all non-medical need on A & E at weekends Initial evaluation identified greater need in the week on wards ASSIST worker now part of the discharge team Monday to Friday, with weekend cover, 2, 5 hour shifts on site with 24/7 Central Control and on call staff (£39,209) Contingency fund (£9,791) to facilitate discharge:- transport costs, access to temporary accommodation, food parcels, purchasing clothing, removals, carpets and furniture, life line, key safe, electricity payment cards, deep cleans, grab rails etc.

9. Outcomes:- In June 2014, KMH was holding100 social care beds in January 2015 this was reduced to 22 50% reduction in medical beds blocked on ward during Perfect Week Minor adaptations reduced stay by 1 – 2 days per patient approx £450 per patient per day Respite assessment flat saving £550 week compared with Transfer to Assess Unit and £3k - £8k per week to remain in hospital

10. Case Study 1

11. Case Study 2

12. Case Study 3

13. Developments:- NCC Social Care fund 4 ASSIST staff based in their integrated teams MDC staff support 2 PRISM teams, START (NCC reablement team) and Mansfield Community Hospital to support transfer to assess beds

14. Non-commission complimentary services:- All staff trained in use of Manga Cushions to assist lifting – used approximately 20 times a month reducing EMAS call out and follow up A & E visits Huge untapped potential to support GP’s with patients with long term conditions and a range of social and complex support needs