We delivered a pilot re-admission avoidance service in February and March which provided home visits for patients who become unwell following discharge from hospital. Our review of the pilot shows that it was successful in preventing 167 re-admissions over a 9 week period.
The aim of the pilot was to test if primary care intervention could help discharge patients earlier or/and keep them at home and avoid re-admission if they have subsequent complications.
The service provided:
- Home visits to support urgent primary care discharge needs e.g. home blood tests within a week or social mental health support to connect patients into voluntary sector organisations.
- GP remote assessment, paramedic home visits, or blood tests for patients when there was an exacerbation of the original admission condition/symptoms within 30 days of discharge.
GP practices will be able to book visits for patients who have been discharged from hospital in the past 30 days and require an urgent response to prevent re-admission.
The service dealt with 269 patient referrals in the 9 weeks it was operational and avoided 167 patients being re-admitted into hospital.