What does it take to get someone home from hospital when they are medically fit but lacking confidence? In Merton, the council’s reablement team offers the support to help people return, as closely as possible, to the life they had before.
First on the ground after a hospital discharge are reablement officers – like Irma Sango. Within two hours of someone coming home, Irma will be at their property – sometimes even before the ambulance crew arrives. “We are very proud of our reablement service, we’re a strong team,” said Irma. “For us it’s all about enabling the person to regain their independence and stay living at home for as long as possible”.
According to Merton Council’s cabinet member for health and social care, Peter McCabe: “The results are really impressive with 75% of people being able to live independently at the end of that time and not go back to hospital.”
Once you’re in the home, that’s when the happiness starts”
Irma describes a typical visit. “Once you’re in the home, that’s when the happiness starts. You have a chat with the customer, make a cup of tea. We call it a ‘settle in visit’. That’s our purpose that evening, to see how they are and check that the environment is clean and there are no hazards.”
People are referred to the service before they are discharged from hospital. Reablement is about working with the patient, putting in realistic goals and giving them support to achieve them. Visits can last for up to six weeks in a continual process of assessment, as people grow in independence.
According to Irma, the following day is when the in-depth work starts. “That’s when we get to know the person better, assess them and make a tailored plan. They might need occupational therapy or physio, or input from the mental health team. Sometimes we need the handyperson service to move furniture around and install a key safe – the list is endless.
“We also find out about each person’s support network, whether they are a member of a church or a club, so they can get back to doing the things they enjoy.”
For some people it’s about accessing new services – those provided by Wimbledon Guild, Age UK Merton or Merton Vision, for example. The team also refers family members for carers’ assessments, which can open up financial support, respite and befriending.
We try to get the client to do as much as they can for themselves, that’s what reablement is all about”
The day after discharge the patient begins receiving visits from reablement support workers like Leigh Holder and Amanda Kenyon.
“We go in, read the care plan and assess what needs to be done. We try to get the client to do as much as they can for themselves, that’s what reablement is all about,” said Amanda.
Leigh added: “Sometimes we liaise with the GP and pick up medication. Sometimes we need to do shopping because people have no family. We’ve got to be prepared to buy anything and everything as sometimes people don’t even have a flannel to wash with or any soap.”
Every patient’s experience of coming home from hospital is different but many surprise themselves with the progress they make.
The oldest person I’ve been to is 105. We help people achieve what they want to achieve”
“Age is not always a barrier, it is never an inevitable decline,” said Leigh. “The oldest person I’ve been to is 105. We help people achieve what they want to achieve.
“We had a client who was really traumatised. She’d had a severe infection and a catheter fitted and was very anxious. She and her husband, who was her carer, were in their 80s.”
“We knew her husband had a bad night because he was standing at the door waiting for us,” said Amanda. “He was very capable, but so stressed because he could see his wife’s distress. It was all new to him.”
When we go into someone’s home we are constantly assessing that person to ask what can they do for themselves
“Our role was to be calm and methodical, to address each thing that was causing concern,” said Leigh. “We got in touch with the GP for her anxiety and the district nurses because the catheter was a worry. We organised the Mascot alarm service because she was very anxious if her husband left the room. As we addressed each of these things, she was able do more for herself. It’s about building confidence.”
According to Irma: “After two weeks I called that lady, and she paid the support workers so many compliments. She said, ‘Irma I don’t need your service anymore’. That was a very very good result.
When we go into someone’s home we are constantly assessing that person to ask what can they do for themselves”
“When we go into someone’s home we are constantly assessing that person to ask what can they do for themselves; will they benefit from a grabber; will a trolley enable them to sit and make a meal and transport it into the dining room? These little things, the reablement service does on a daily basis.
“Some people will never be as well as before they became ill. We approach them with the same attitude, giving people as much choice as they want in their circumstances.
“Another gentleman was receiving four calls a day. He’d had a nasty fall and couldn’t walk, and he wasn’t eating properly. We went out to him. We were able to get dietician involved, and his family. We got his environment tidied up, involved physios, and within three weeks we were able to reduce his package of care. Within another week he was driving – he went out in his car with a friend. That’s what we like, that’s the feelgood factor!”