New Hospital Discharge Social Prescribing Project - Community Bridge

The authority has commissioned Dudley Council for Voluntary Service (Dudley CVS) in collaboration with NHS partners to deliver a new social prescribing two-year pilot that will enable a range of voluntary sector organisations to deliver support in the community to help people live independently following a stay in hospital.

Volunteers, social prescribers and voluntary organisations will work together to help bridge the gap between hospital and home, addressing the non-clinical factors which can delay discharge or contribute to avoidable readmission. Social prescribing connects people to practical, social and emotional support that tackles the root causes of poor health such as loneliness, debt, housing issues or lack of confidence.

Simple steps such as linking isolated residents to befriending groups, encouraging those with physical health conditions to take up accessible exercise, helping people to make new friendships and take part in social activities, supporting people in financial difficulty to access organisations such as Citizens Advice means that people feel supported beyond the hospital environment and empowered to live independent lives.

While the service supports safe and timely discharge from hospital, it is deliberately designed to extend well beyond the hospital setting. Volunteers and staff from a range of voluntary sector organisations will provide up to 12 weeks of intensive, community-based support after a resident returns home — a period when people are most at risk of deterioration, loss of independence or readmission. This approach helps reduce avoidable readmissions and ensures support continues beyond clinical care and into everyday life.

Dudley CVS has over ten years of experience in social prescribing and was one of the earliest social prescribing services in the country with a dedicated funding programme for frontline voluntary sector organisations to support interventions in the community. This new pilot will enable an expansion of social prescribing into a hospital discharge setting using a voluntary sector collaborative investment model.

Councillor Andrea Goddard, cabinet member for health and adult social care, said:

“As part of the remodelling of our Adult Social Care provisions, we are progressively shifting towards a prevention first, place based model that strengthens community resilience, reduces avoidable hospital admissions, supports timely discharge, and enables residents to remain independent in their own homes.

“The hospital discharge social prescribing pilot – Community Bridge Project is a perfect example of how we can work smarter and allow more people to stay in their own homes for longer. Dudley CVS have proven that this model works, and I’m really pleased that we’ve been able to invest in the voluntary sector to deliver this service.”

Kate Green, Deputy Chief Officer Dudley CVS, said:

“Leaving hospital is a critical moment in someone’s recovery. Enabling and supporting voluntary sector involvement through a bespoke funding programme will mean that the sector can play an integral part in helping people live healthily and independently.”

Community Bridge Project is match-funded by Dudley Council, The Dudley Group NHS Charity, Black Country Volunteering for Health and Black Country Integrated Care Board.