Case studies

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.

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.

CURO is a not-for-profit housing and support organisation based in Bath, providing affordable homes and care and support services across the West of England. This example of a local initiative forms part of our managing transfers of care resource.

Homerton University Hospital’s movement towards seven-day working to improve patient flow has been a long journey that has taken a few of years and gone through a number of iterations in terms of changes to systems and processes. This example of a local initiative forms part of our managing transfers of care resource.

In the context of Leicestershire’s county wide Integration Programme, housing, health and social care, partners recognised a major opportunity to radically redesign housing support, moving away from a historically fragmented set of services and constructing a new integrated housing offer focused on health and wellbeing outcomes, such as maximising independence in the home and preventing falls. 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.

Wirral has a large number of care homes and had a significant number of non-elective admissions from care home residents. It was a priority to ensure that care was provided in the patient’s place of residence wherever possible, as a non-elective admission can have a detrimental effect on frail older people. This example of a local initiative forms part of our managing transfers of care resource.

The objective of the project was to eliminate the barriers above and to implement the ethos of Home First due to recognising the importance and value of people being more likely to improve, adapt and recover in their own homes. This example of a local initiative forms part of our managing transfers of care resource.