Case studies

Partners in Leicester have taken a five-stage approach to improving discharge and avoiding unnecessary admissions. This example of how local areas are working to implement overall system change forms part of our managing transfers of care resource.

Over the past five years, the use of the single health resilience early warning database (SHREWD) has enabled Kent County Council to supply real-time data to support internal management and also operational partners. This example of a local initiative forms part of our managing transfers of care resource.

Managing transfers of care: an example of how a local area is working to implement system change. The system in North Staffordshire faced a number of issues, including risk-averse practice and fragmented services in the community. This example of a local initiative forms part of our managing transfers of care resource.

In 2014 East Surrey CCG embarked on a project to improve the medical care of residents of nursing and residential homes. This example of a local initiative forms part of our managing transfers of care resource.

The programme aims to tackle loneliness and fragmented care by joining up services for older people in supported living schemes and care homes, to help people live longer, healthier lives at home and within their communities. This example of a local initiative forms part of our managing transfers of care resource.

Bradford District and Craven has a population of around 590,000 people. It is divided into two health and care partnership areas with distinct geographies and demographics. This example of how local areas are working to implement overall system change forms part of our managing transfers of care resource.

In the last year, there has been a major transformation in how partners Ipswich and East Suffolk work together to tackle delayed transfers of care (DTOCs). For example, on 1 February 2018, 10 DTOCs were reported; in the same period in 2017 it was 49. This example of how local areas are working to implement overall system change forms part of our managing transfers of care resource.

To provide an equitable hospital discharge experience for residents whilst improving performance associated to delayed transfers, a bespoke Hospital Discharge Service was established in October 2017, with the use of iBCF monies to expand the council’s ‘discharge team’ located at the hospital where the greater number of admissions historically occurred. This example of a local initiative forms part of our managing transfers of care resource.

In 2014 East Surrey clinical commissioning group (CCG) embarked on a project to improve the medical care of residents of nursing and residential homes (care homes). East Surrey CCG has a significant number of Care Homes with a total of 1,800 beds across the geography. This example of a local initiative forms part of our managing transfers of care resource.

The hospital avoidance response team – HART – service is delivered by members of the Lincolnshire Independent Living Partnership and takes referrals from secondary care discharge hubs, A&E in-reach teams, the ambulance service, primary care and community health providers. This example of a local initiative forms part of our managing transfers of care resource.