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 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.

Prior to the move into the discharge hub, work had already taken place to replace the ward discharge Officers with a more administrative role, new staff were recruited at band 4 on each ward within the Trust. A decision was also made that each directorate would have a supervisor Band 5 post to over-see the work of the discharge officers. 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.

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.

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.

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.

In the context of Leicestershire’s county wide Integration Programme, housing, health and social care, partners recognised a major opportunity to radically redesign housing support, moving away from a historically fragmented set of services and constructing a new integrated housing offer focused on health and wellbeing outcomes, such as maximising independence in the home and preventing falls. This example of a local initiative forms part of our managing transfers of care resource.

The goal of this initiative was to support people to be discharged from hospital quicker and more effectively, whilst also avoiding people going into residential care. This example of a local initiative 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.