Case studies

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.

With the seven-day working strategy, Hertfordshire aimed to improve the flow from the acute into the community, ensuring discharges are not delayed over the weekend while service users wait for a package of care due to processes outside of the Monday to Friday norm. 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.

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.

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.

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.