Overview
In Somerset, system leaders worked together on a shared ambition to redesign intermediate care. An Intermediate Care Board was established to steer the work. Whilst in its infancy, this Board was co-chaired by the DASS and an NHS COO. A transformation partner was commissioned to develop a joint data set, which had been identified as a key area of opportunity.
Action
Features of the work included:
- Development of Terms of Reference for the Intermediate Care Board, which remains in place several years later. The co-chair role (local authority and NHS) is now tied to specific posts, which ensured continuity of the Board if individuals moved on from the organisations.
- In more recent months, a multi-agency Transfer of Care Hub has been established, enabling more effective decision-making and better use of resources and a data-led, cross-system view of emerging issues.
- Implementing a consistent feedback process for those who receive reablement at home is well established. Each person who uses the service gets a QR code which allows them and their carers to fill in a satisfaction survey. This produces a report which can be reviewed by service managers. More in-depth calls are carried out periodically to gather more detailed qualitative data on user and carer.
Outcomes
The transformation programme has led to:
- High proportions of people now returning directly home from hospital. (approx. 95%)
- A reduction in long term care placements directly from hospital
- In December 2025 86% of pathway 1 finishers remained at home.
September-December 2025 pathway 1 survey results showed:
- 100% of respondents felt that receipt of pathway 1 reablement at home helped to make them feel more confident at home.
- 100% of responding carers fed back that they were confident to continue to support their loved one after the reablement period ended.
- 96% respondents fed back that overall, their reablement goals had been achieved.
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