Mrs Bentley* is a 52 year old Croydon resident. She works locally as a secretary and has suffered fibromyalgia and acute asthma for many years. Earlier this year she was admitted to hospital for three months with Covid-19, which resulted in her being diagnosed with diabetes. Mrs Bentley now needs regular kidney dialysis to manage her diabetes.
Local residents like Mrs Bentley need health and social care support in different ways and different points of their life – for some this may be after a hospital stay, an illness or an injury, which may require temporary care. Whatever the circumstance it’s important that support is available to help people get back on their feet and regain independence. This temporary care is called reablement.
Working together as part of the One Croydon Alliance (a partnership of NHS organisations, Croydon Council and the voluntary sector), the Living Independently For Everyone (LIFE) team supports residents to regain independence at home after a hospital admission. Since 2017 the integrated health and social care team of community nurses, physiotherapists, occupational therapists, social workers, reablement support workers and health and wellbeing assessors have supported 4300 Croydon residents back to health in the community.
Health and care professionals assess resident’s needs and co-ordinate community health and care services to ensure they have the right support when they are discharged from hospital. This approach enables Croydon residents to conveniently get the personalised care they need to recover at home, whilst easing demand on hospital beds for those with more complex conditions.
I had a positive experience of the care providers who supported me at home. The care I received has exceeded expectations.
Mr Ali, LIFE programme patient
Mrs Bentley and the LIFE team
Once discharged from hospital, Mrs Bentley was supported by a social worker, physiotherapist occupational therapist and reablement worker who delivered care and helped her to set recovery goals to improve her health and wellbeing.
After 6 weeks of support at home, Mrs Bentley was able to confidently mobilise with a mobility aid, carry out her own personal care, engage with church friends and attend family events.
Understanding the need for more long-term support to maintain independence, the LIFE team also supported Mrs Bentley to claim the Personal Independence Payment social care benefit which allowed her to rent a mobility scooter to make her trips to the shops and hospital appointments easier to manage.
Jennifer Daniel, LIFE Service and Development Manager, shared more about the service
Personalised recovery plans
“Following an assessment by a LIFE health and wellbeing assessor or social worker in hospital, we create personalised plans to support physical and mental health recovery in the community once discharged. Caring for patients recovering from ailments such as a bone fractures, hypertension, or dementia our community team of health and social care professionals care for our patients back to good health for up to six weeks. In response to individual need, care packages may include physiotherapy and personal care, such as support for dressing, completing kitchen tasks and community walks to build confidence with shopping.”
Multi-disciplinary working
“Our team members take part in weekly multi-disciplinary team reviews with doctors, nurses, pharmacists, social care workers, voluntary and community sector colleagues to review individual cases and co-ordinate the care to meet the needs of people with complex care needs. This joined up approach allows us to jointly create and deliver more person-centred care to support patient recovery.”
Long term community support
“We’re focused on delivering quality and personal care to support independence, where we’re able to not only support a patient’s clinical recovery, but also their wider wellbeing. We encourage patients and highlight opportunities for them to live well as part of their local community by accessing more long term support services, such as New Addington Community Hub, where they can access free information about healthy living, housing, employment services, disability and carers support.”
LIFE team eligibility
The LIFE team supports people that can be reabled in the community environment either in their own home or in a Step Up/Down intermediate care bed if they are:
- 18+ years of age
- a resident of Croydon
- need a health and/or social care assessment within the community environment
- have reablement /rehabilitation potential
*The names of patients have been changed to main confidentiality.