Case studies

Home First is an initiative developed through the partnership of Medway Foundation Trust Hospital, Medway CCG, Medway Council and Medway Community Healthcare. It provides support for patients medically fit to be discharged, but who still require additional home support. This example of a local initiative forms part of our managing transfers of care resource.

The approach to implementing trusted assessment involved identifying the best team to develop trusted assessment – using an interface team of nurse, physiotherapist, occupational therapist and social worker. The approach to implementing trusted assessment involved:

Joint contracting arrangements – for care homes, community based and voluntary sector provision – are headed up by the director of integrated commissioning, with lead commissioners incorporating children and maternity, disabilities and older people. This example of a local initiative forms part of our managing transfers of care resource.

The ASSIST– advocacy, sustainment, supporting independence and safeguarding team – scheme brings together teams from the district council, Nottinghamshire County Council, Sherwood Forest Hospitals NHS Foundation Trust, Mansfield and Ashfield Clinical Commissioning Group, and Nottingham Trent University. This example of how local areas are working to implement overall system change forms part of our managing transfers of care resource.

Following a review by the Emergency Care Improvement Programme (ECIP) in October 2016, County Durham and Darlington Local Area Delivery Board has implemented a system-wide set of changes to improve performance. This example of a local initiative forms part of our managing transfers of care resource.

In East Surrey, adult social care and the CCG are working together to pilot the use of discharge to assess for all continuing healthcare (CHC) assessments. 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 Sutton, the 'red bag' contains standardised paperwork, medication and personal belongings, and it stays with a care home resident from the time they leave the residential home to go to hospital until the time they return to their care home at the end of their stay in hospital. This example of local initiatives forms part of our managing transfers of care resource.

Sheffield, like other areas across the country, has found itself under a lot of scrutiny both regionally and nationally because of its delayed transfers of care (DTOC) performance. This example of how local areas are working to implement overall system change forms part of our managing transfers of care resource.