Case studies

Managing transfers of care: an example of how a local area is working to implement system change. Kent’s transformation journey began in 2013 with the establishment of three programmes on care pathways, optimisation, and commissioning. 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.

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.

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.

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.

Managing transfers of care: an example of how a local area is working to implement system change. The system in North Staffordshire faced a number of issues, including risk-averse practice and fragmented services in the community. This example of a local initiative forms part of our managing transfers of care resource.

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.

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.

Managing transfers of care: an example of how a local area is working to implement system change. The model in Hull, which forms part of a system- wide approach to reducing delayed transfers of care, is based on the principle of ‘active recovery’.