Posted on 18/10/2018 by
"I locked myself away, I was in a rut. I couldn't go out. I couldn't walk, it was killing me."
Viv Page, 67, struggles with his mobility and has chronic obstructive pulmonary disease.
His daily life at home in Cardiff was a "nightmare" until support worker Asia Ibrahim from Cardiff council's independent living service arrived on the scene.
A mobility scooter has already allowed him to get back out in the outside world.
She is also arranging a walk-in shower for him after he fell from his bath and banged his head, and a stair lift so he can get to the toilet upstairs, rather than use a bleach-filled bucket in the kitchen or go to his partner's house.
These adjustments will keep him independent and, hopefully, out of hospital.
Historically though, there have been issues with patients stuck in hospital because they need similar equipment and support at home.
Now a new project developed by Cardiff and Vale Regional Partnership Board means this kind of help will soon be more readily available for people who are preparing to be discharged from hospital.
The aim is to improve coordination between health and council services.
Patients will be assessed by the council - including housing and social services - while they are in hospital so they do not stay there longer than necessary.
From hospital beds to men's sheds
The in-hospital assessment of care needs is one of seven elements of a new £7m Cardiff and Vale project.
It will be the first to receive funding from the Welsh Government £100m "transformation fund".
The fund is for health boards, councils and other organisations to work together to develop new ways of delivering health and social care and to reduce pressure on the NHS.
The Cardiff and Vale project is called Me, My Home and My Community and is a partnership between the NHS, council services, charities and the voluntary sector.
As well as assessing people in hospital, the project will allow health and social care professionals to share information about patients, as well as introducing more community projects such as "talking cafes" and "men's sheds" to improve wellbeing.
There will also be more links with volunteer care workers and people needing care, and better communication between different health workers to identify people who are more vulnerable and need support.
Caroline Palmer, from Cardiff council, said that communication between the NHS, councils and other organisations had improved.
"We're there at the first contact to talk about discharge. We get involved as early as possible to help them transfer from the hospital to their homes," she said.
"The difference is that we'll have services that wrap around them, so health, social services and anything else they might need."
Getting the support he needed has felt life-saving to Mr Page.
"Without my support worker I would have ended up not going out and my independence would have gone.
"I might have been dead by now."