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Supporting People at Home

Supporting people to live at home as they develop or encounter health-related difficulties is a core ambition of health and social care. Achieving this requires resilient, responsive, accessible and adaptable health and care services that have personalised care principles at the heart of what they deliver and work in tandem with the individual, their friends and family carers to help people achieve positive outcomes.

The impact of not supporting people effectively at home is experienced both at an individual level and across our health and care system through increased demand on urgent and emergency care services and social care.

There is an important equality aspect to this priority as we know that some cohorts of our population seek support from health and care services earlier on, whereas others delay seeking help until at or close to crisis. This priority is therefore important to improve the experience and effectiveness of care and support within our system.

By focussing on this priority area our aim is to provide support, across health and care and with wider partners, to enable people to be supported within their own home environment.   

This will support the delivery of the ICS vision through:

  • supporting residents to lead an independent life
  • enabling people to remain in their communities for longer
  • improving sustainability of services by helping focus hospital services on those who absolutely cannot be supported at home.


What are we doing already?

In Coventry, the Improving Lives programme presents the opportunity to significantly transform how older people are supported by organisations working together across community support, hospital processes and discharge/reablement.  Although this programme is focussed on people aged 65 and over there will be benefits to other cohorts of the population.

In Warwickshire, the Hospital Discharge Community Recovery Programme presents an opportunity to further develop pathway 1 (support at home) discharge to assess services in Warwickshire to enable all people in an acute hospital, who need further support, to access timely therapeutic intermediate care services on discharge. 

Across both Coventry and Warwickshire, the learning from these programmes will be shared as the work progresses – this sharing and learning will enable the interventions with greatest impact to be used to accelerate progress across the whole system.

We are also working on ageing well and specific frailty programmes which have been making progress in our support for older people.  We have a Proactive Care at Home workstream which is supporting individuals in their own homes and in care homes. These system wide programmes will connect with the Coventry and Warwickshire specific programmes to make a step change in how people are supported.

We have recently implemented an Integrated Care Records system which is being rolled out to all organisations.  This enables health and care records to be shared, which leads to better informed professionals, who will be better able to support people as a result.


What will change in our ways of working?

  • An improved and more responsive coordination and delivery of health and care within an individual’s own home when urgent and emergency care is required – this will help prevent people making unnecessary visits to hospitals.
  • Where ongoing support (health or care or both) is required to enable people to continue to live independently, this will be reliable, sustainable and responsive to change as people’s requirements change.
  • Where people are required to visit hospital for treatment, this will be undertaken in a patient-centred and effective manner, with the focus on returning home as soon as possible.
  • Where people have had a change in their health as a result of deterioration or a specific episode in their life, they will be supported to recover and re-abled to maximise their individual outcomes.


What actions are we prioritising?

  • In Coventry, development and implementation of an integrated model that focusses on support at home and stemming the ‘flow’ to hospital settings whilst reabling people to regain independence they may have lost as a result of a health episode.
  • In Warwick, further development of pathway 1 (support at home) discharge to assess services in Warwickshire to enable all people in an acute hospital, who need further support, to access timely therapeutic intermediate care services on discharge.
  • Taking the opportunities presented by the social care reforms to support people to live independently, whether through housing, innovation, or use of technology.
  • Supporting informal family carers – our ambition to support more people to be independent at home will also require us to consider how we work with and support informal carers who are a critical and integral part of the care and support system.