Case studies

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.

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 Trust decided to implement an electronic system to find a better way of managing complex discharges in 2013. This was developed in APEX, a low-code development platform that enables an organisation to build scalable and secure apps. This example of a local initiative forms part of our managing transfers of care resource.

‘Transforming our Communities’ was a consultation undertaken by Hambleton, Richmondshire and Whitby, and helped to provide a mandate for the local system to develop new models of care closer to home. 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.

Active Herts is a research led and independently evaluated project which uses evidence-based behaviour change techniques to support inactive adults to increase their physical activity levels.

Public health in Portsmouth is threatened by poor air quality. Across the UK, it is estimated that air pollution contributes to between 28,000 and 36,000 deaths per year.

NHS Newcastle Gateshead clinical commissioning group (CCG), was selected to be part of NHS England New Care Models Care Home Vanguard Programme. One of the initiatives to be introduced was the ‘transfer of care bag’, which sought to improve communication between hospital and care home teams when residents moved between both settings. This example of a local initiative forms part of our managing transfers of care resource.

Staff from Gateshead’s substance misuse service have a presence at the borough’s main hospital four days a week. This gives them a chance to identify and engage patients who have alcohol-related problems.

New ways of engaging young people are being explored in Lancashire thanks to a government-funded project. Non-alcohol specialist staff are getting extra training and early intervention work is taking place with teenagers and families.