Case studies

In Barnsley, South Yorkshire, a Macmillan Social Worker is employed by Barnsley Council to sit within the multidisciplinary team of clinical nurse specialists, occupational therapists and dieticians to provide expert support for people in need of complex palliative care and support at end of life. This case study forms part of our end of life care guide for councils. This case study forms part of our end of life care guide for councils.

Greater Manchester H&SC Partnership decided that a resource pack would be a useful resource to create to promote innovation, best practice and improve commissioners understanding of workable models of housing with care.

A new integrated adult Community Learning Disability (LD) Team has been uniquely co-located with children’s social care and education services in purpose-designed premises to improve outcomes for residents of all ages with disabilities.

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 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 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.

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.

In 2014 East Surrey clinical commissioning group (CCG) embarked on a project to improve the medical care of residents of nursing and residential homes (care homes). East Surrey CCG has a significant number of Care Homes with a total of 1,800 beds across the geography. 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.