Case studies

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 ASSIST– advocacy, sustainment, supporting independence and safeguarding team – scheme brings together teams from the district council, Nottinghamshire County Council, Sherwood Forest Hospitals NHS Foundation Trust, Mansfield and Ashfield Clinical Commissioning Group, and Nottingham Trent University. This example of how local areas are working to implement overall system change 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.

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.

The approach to implementing trusted assessment involved identifying the best team to develop trusted assessment – using an interface team of nurse, physiotherapist, occupational therapist and social worker. The approach to implementing trusted assessment involved:

For Newcastle Gateshead CCG, one of the very best things occurring as a result of being part of the NHS England New Care Models programme has been the opportunity to test and evaluate new models. This example of how local areas are working to implement overall system change 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. This initiative focuses on older people living with frailty and very complex needs in care homes. This example of a local initiative forms part of our managing transfers of care resource.

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.

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.

‘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.