Supported Hospital Discharge: How the Community Home First Team Helped a Gentleman with Parkinson’s Return Home

When a gentleman living with Parkinson’s Disease was admitted to the Countess of Chester Hospital following a fall, his family expected his stay to be short. They had been caring for him lovingly and effectively at home for a long time. But as the days passed, they noticed a worrying change: his mobility and mental capacity had declined far more than they anticipated. This was not unusual for someone with Parkinson’s experiencing the disorientation, inactivity and disruption of a hospital stay — but it left his family anxious about what would happen next.

The Community Home First Team.

It was at this point that the Community Home First (CHF) Team became involved.

The referral arrived after one of the CHF team members spoke with the family and recognised their growing concerns about managing once he returned home. Their home had always been a place of comfort and routine, but it was also a traditional two-storey layout — and the gentleman’s newly reduced mobility meant he would no longer be able to access the stairs. For his wife, the idea of him returning home without a safe sleeping space was frightening. There was simply no room for a bed downstairs, and although she had long wished to adapt the home, the cost was more than the family could afford.

When the CHF practitioner contacted his wife, the conversation was open and honest. She understood her husband’s care needs well, but she had no idea what support systems existed or how to access them. She knew what she wanted for him — to come home, stay home as long as possible, and maintain dignity — but she didn’t know what was possible.

Connecting the Hospital Teams to support the family.

With this information, the CHF practitioner reached out to the hospital Occupational Therapist (OT) overseeing his care. While the OT was fully aware of his mobility challenges, she had not yet been informed of the practical limitations of his home environment. The CHF practitioner was able to explain the situation clearly: without adaptations, returning home safely was not feasible. This understanding prompted the OT to take immediate action. She arranged a referral into Social Services as soon as the patient was medically optimised for discharge, allowing plans for essential adaptations and support to begin.

Recognising the complexity of his needs, the OT also organised a joint meeting with the Integrated Discharge Team (IDT), the Complex Care Team and the nursing staff. This collaborative approach ensured every professional involved had a full picture — not just of the gentleman’s clinical condition, but also of his family’s wishes, the physical constraints of their home, and the broader support required to make a safe discharge possible.

One of the most striking aspects of the case was how easily critical details could have been overlooked. Hospital staff understood he could not manage the stairs, but they did not realise that meant he would have no accessible bed at all once home. No one had previously asked the family how they had been managing before admission, nor what environment they were returning him to. It was only through the CHF practitioner’s conversation with his wife that these issues came to light.

A positive outcome for all.

Thanks to this open communication, thoughtful listening, and a joined-up approach across teams, potential barriers were identified early and unnecessary complications avoided. The gentleman’s family — devoted, capable and eager to resume caring for him — felt heard and supported. Plans for adaptations, equipment and social care were set into motion before discharge rather than after a crisis arose.

This case highlights exactly why the Community Home First Team exists: to bridge the gap between hospital and home, to advocate for patients and families, and to ensure that returning home with supported hospital discharge is not only possible but safe, sustainable and centred on dignity.