Case studies

Often due to pressures and trouble identifying someone at the home who could carry out assessments, it took up to a week for a home to visit. Lincolnshire introduced a care home trusted assessor role, which would not only enable assessments to be carried out more quickly, but would also help to develop relationships and trust across the system. This example of a local initiative forms part of our managing transfers of care resource.

‘Transforming our Communities’ was a consultation undertaken by Hambleton, Richmondshire and Whitby, and helped to provide a mandate for the local system to develop new models of care closer to home. This example of a local initiative 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.

In late 2017 the Technology Enabled Care (TEC) team began working on a project to improve pathways and access to TEC for those who were being discharged from hospital. The aim was to significantly increase the take-up of lifelines and telecare within a vulnerable cohort that would most benefit from them and ensure that people had access to the councils in house Reablement Enhanced Response Service (ERS). This example of a local initiative 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.

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.

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.

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.