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New project helps vulnerable people return home after hospital

Discharge to Access (D2A) and community teams have collaborated to help vulnerable people after a stay in hospital.
The short-term enablement project is helping to deliver the strategic aims of the national hospital discharge policy, which requires people to be discharged from hospital within 24-hours of a decision that they are medically fit. This means they no longer need hospital care.

The project is delivered by statutory and voluntary organisations, providing of assistance for vulnerable people to help them safely return home.

The project offers a range of practice support for example, ensuring the heating is on, the home is clean or de-cluttered, there’s food in the fridge and clean clothes available. Help can also be provided for financial management, personal assistance and finding local support networks.

The project is part of a pilot with NHS England and NHS Improvement (NHSEI).

The project

The short-term enablement project has helped people like Tom* after an emergency hospital admission

Tom is 74 and a double amputee and suffered a fall hitting his head whilst living in temporary accommodation, causing a brain aneurism. He had no family close by and his main companions were his dogs, who were taken on by a local kennel when he was admitted.

He spent 2 months in hospital rehabilitating. When he was physically ready to leave hospital, his mental health was low and he was very anxious about the uncertainty of where he was going to live. He was struggling with the paperwork involved in organising a permanent home, finances and ongoing his medical appointments.

Rose Foxwell hospital discharge officer at Cornwall Rural Community Charity was assigned to help Tom, as part of the short-term enablement project.


Tom was discharged from hospital into temporary accommodation in a Travelodge, this increased Tom’s low mood, anxiety and general ill health as he was alone in his room with no cooking facilities. Rose raised safeguarding concerns and spoke to a local foodbank who agreed to deliver food to Tom whilst he was at the hotel. He was then provided with accommodation in a bed and breakfast where the property owner provided Tom with cooked meals and general support.

Rose organised health check-ups and benefits applications to help improve Tom’s finances. Sadly, Tom’s mental health declined severely when his daughter died by suicide shortly after he had been discharged from hospital. With his accommodation being short term and fearing he was to become homeless, Tom attempted to take his own life.

Thankfully, Tom was unsuccessful and when he recovered from his suicide attempt, Coastline housing provided a bungalow on the Lizard for him to move in to with his dogs. Rose continued to support Tom as he settled into a new life in a new village.


There were a number of issues that needed to be resolved to help Tom stay healthy and avoid getting sick again:

  • Tom’s housing situation was impacting his mental and physical health
  • his mobility meant he had specific housing needs
  • memory issues and lack of confidence with technology and phone meant Tom struggled to keep up with paperwork and appointments
  • Tom’s dogs are his life and getting them back was paramount to his health and wellbeing

Outcomes and solutions

The support that Rose provided via the short-term enablement project has helped Tom back to independence through:

  • advocacy to ensure funding and benefits
  • funding secured: COVID funding, crisis grant, short term enablement fund, Coastline hardship fund
  • support with technology, applications and appointments helped Tom to get physically and mentally better
  • GP contacted to ensure Tom had support for his mental health
  • finding suitable Tom a home and organising furnishings, domestic appliances and mobility assistance
  • the return of his dogs, meant that Tom leaves the house for regular exercise which has lifted his mental health and improved his physical health
  • befriending Tom, building rapport, becoming part of his support network and helping him to build a wider network of friends and agencies to support him in future

Next steps

The short-term enablement fund will allow a personal assistant (PA) to be provided for Tom. The PA will help him to live independently and assist with organising mobility aids to be installed around his home, as well as help him become more digitally savvy so he feels confident with online banking and transacting.

Tom says he is feeling healthier and happier, he loves his house and the village he now lives in.

Tom’s words

Tom said: “When I met Rose, I felt helpless, I didn’t really feel like life was worth living, everything just seemed too difficult, I was a bit lost for a while. Now I am settled in my home with my dogs and am making friends with people in the village, I feel much better. I go walking by the sea every day with my dogs and am thankful for everything Rose has done for me. I am still learning, being a technophobe, I need help with using my smart phone, especially banking. Rose is always there for reassurance. She has helped me with getting some appliances for my home. I feel stronger and more confident.

“I went to the village shop the other day and the lady behind the counter said I was an asset to the village. That made me happy. I just want to say thank you to Rose for all she does, she is like a pair of crutches for me, I don’t know where I would be without her.”

*Name has been changed for privacy

More stories from the D2A short-term enablement project

Watch another partner in the project, Disability Cornwall, talk about the support they provide people leaving hospital.

Added on 24 June 2021, in News - People’s stories

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