Case studies

Managing transfers of care: an example of how a local area is working to implement system change. The model in Hull, which forms part of a system- wide approach to reducing delayed transfers of care, is based on the principle of ‘active recovery’.

Managing transfers of care: an example of how a local area is working to implement system change. Kent’s transformation journey began in 2013 with the establishment of three programmes on care pathways, optimisation, and commissioning. This example of a local initiative forms part of our managing transfers of care resource.

Since October 2013, an integrated discharge team has been up and running in North Kent. The team aims to reduce admissions, ensure patients’ needs are proactively managed to reduce their length of stay and to enable patients whose medical conditions are stable to leave hospital in a timely manner. This example of a local initiative forms part of our managing transfers of care resource.

Over the past five years, the use of the single health resilience early warning database (SHREWD) has enabled Kent County Council to supply real-time data to support internal management and also operational partners. 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.

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.

Partners in Leicester have taken a five-stage approach to improving discharge and avoiding unnecessary admissions. This example of how local areas are working to implement overall system change forms part of our managing transfers of care resource.

Often due to pressures and trouble identifying someone at the home who could carry out assessments, it took up to a week for a home to visit. Lincolnshire introduced a care home trusted assessor role, which would not only enable assessments to be carried out more quickly, but would also help to develop relationships and trust across the system. This example of a local initiative forms part of our managing transfers of care resource.

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.

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.