Overview
Redcar and Cleveland were experiencing discharge delays across the local system, and intermediate care bedded provision was not leading to return home as frequently as would be expected.
Action
Colleagues undertook a diagnostic to understand data and flow, and designed a new, integrated delivery model called ‘No Place Like Home’. The approach is designed to avoid unnecessary hospital admission, accelerate discharge, and maximise independence by ensuring that home is the default setting for recovery and ongoing support. No Place Like Home has a clear vision and purpose, built around keeping people independent, safe, and supported at home, with bed-based IMC used only when necessary.
The model is based on:
- Neighbourhood‑based multidisciplinary support teams combining community nursing; social care, therapy, reablement, housing, equipment and VCSE partners to promote rapid assessment, same day intervention and continuity of care close to home.
- A redefined role for a local site as 4-bed intermediate care provision, with the aim of preparing people to return home quickly.
- Assistive technology and equipment – using technology‑enabled care, home adaptations, and rapid equipment provision to keep people safe at home and reduce reliance on bed‑based care.
- Strength‑based, independence‑first practice – support built around what people can do, not what they can’t. Therapy‑led plans focus on mobility, confidence, and daily living skills.
Jointly with Middlesbrough Council and James Cook University Hospital, colleagues developed a Transfer of Care Hub to coordinate discharge support, and provide the link into No Place Like Home.
Outcomes
- Fewer avoidable admissions through rapid community intervention.
- Faster discharge because home‑based support is ready and coordinated.
- Reduced length of stay by using intermediate care as a short, therapy‑led bridge home.
- Improved independence outcomes through reablement and assistive technology.
- Stronger neighbourhood resilience via integrated teams and community assets.
Peers to contact
Cara Nimmo: [email protected]