Many people with mental health issues are inappropriately admitted to hospital, or spend longer than necessary as in-patients, because they don’t have the support they need to return home.  

This has a detrimental effect on their recovery and quality of life, but also, these unnecessary admissions, readmissions, and expensive in-patient treatments, come with a hefty bill for the taxpayer.  

The Bridge Back Home (BBH) Team has been working in conjunction with the Oxleas Clinical Home Treatment Team (HTT) in Greenwich since July 2021. Our aim is to improve patient experience, reduce the number of hospital readmissions and reduce the average length of hospital stays. 

We are delighted to report that we have been very successful. What follows is an overview of the service since inception.  

Success stories 

The BBH Team works with other providers in the community to address the various issues that affect a person’s ability to live independently, not just mental health issues. 

Here are some examples: 

1. An older gentleman with PTSD and multiple physical health problems was struggling with day to day life due to anxiety, paranoia, sleep problems and housing issues.  

• BBH was able to identify stress factors and help him develop coping mechanisms. He found these extremely helpful. 
• His housing issues were dealt with. He had mould and had been waiting for repair work. He had also been waiting a long time for repairs and upgrades to his kitchen and bathroom. BBH was able to arrange for this work to be done urgently and made suitable for his needs.  
• BBH staff have been accompanying him out more often and as a result he is now more comfortable to go out on his own. 

2. A 28 year old female was referred to the BBH Team with anxiety, depression and other mental health issues. She had various stressors contributing to her low mood and suicidal thoughts. These included stressors from work, finances and from her living conditions relating to repair work that needed to be completed. 

• BBH were able to chase up and complete all outstanding work in her home (leaks, mould, and mice infestation, etc).  
• She signed up to a mental health skills workshop and as a result she was able to return to work with the support of the BBH Team. 

Achievements 

Since the 1st of July 2021, the BBH service has achieved: 

• 232 accepted referrals. 
• An average discharge time of only 2 days to 6 weeks from referral date (often the delay in discharge can be up to 6 months). 
• Only 8 readmissions in 11 months (for mental health reasons as opposed to social care reasons). 

The savings on an average bed say of 37 days are astounding. Based on the 232 accepted referrals at £500 per night, as of 1^st June, the BBH Team has saved the NHS £4,127,000. 

The cost of running the Bridge Back Home Team over the same 11-month period – £275,000.  

As you can see, the results that the BBH team have achieved for clients are amazing and the savings to the NHS are tremendous! 

What’s next for BBH 

The review highlighted that social needs are the predominant factor in preventing timely discharge from hospital and that people rarely come back to hospital if the pre-discharge work is timely and thorough. 

Also reported during the review were high rates of dissatisfaction with the current process. The clinical role is not trained, nor has time, to effectively discharge patients in a timely manner. 

We found low referral rates from the hospital. Moving forward it would be beneficial to see the wards embracing and working with the BBH team more effectively. 

We are committed to continuing to improve our service and continue our success, taking into account any necessary improvements we have identified over the last 9 months.  

We are proud and excited to share these results. If you’d like any further information about our BBH service please don’t hesitate to contact us.