Case studies

Since October 2013, an integrated discharge team has been up and running in North Kent. The team aims to reduce admissions, ensure patients’ needs are proactively managed to reduce their length of stay and to enable patients whose medical conditions are stable to leave hospital in a timely manner. This example of a local initiative forms part of our managing transfers of care resource.

In September 2016 these separate schemes were merged to form the admission avoidance and discharge service (AADS). This example of a local initiative forms part of our managing transfers of care resource.

Success for partners in Blackburn with Darwen has been achieved through shared recognition of a problem, and a commitment to developing a solution, and testing, revising and taking it further. 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.

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.

Wirral has a large number of care homes and had a significant number of non-elective admissions from care home residents. It was a priority to ensure that care was provided in the patient’s place of residence wherever possible, as a non-elective admission can have a detrimental effect on frail older people. This example of a local initiative forms part of our managing transfers of care resource.

The objective of the project was to eliminate the barriers above and to implement the ethos of Home First due to recognising the importance and value of people being more likely to improve, adapt and recover in their own homes. This example of a local initiative forms part of our managing transfers of care resource.

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.