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.

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.

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 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 late 2017 the Technology Enabled Care (TEC) team began working on a project to improve pathways and access to TEC for those who were being discharged from hospital. The aim was to significantly increase the take-up of lifelines and telecare within a vulnerable cohort that would most benefit from them and ensure that people had access to the councils in house Reablement Enhanced Response Service (ERS). 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.