Case studies

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.

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.

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.

In East Surrey, adult social care and the CCG are working together to pilot the use of discharge to assess for all continuing healthcare (CHC) assessments. This example of a local initiative forms part of our managing transfers of care resource.

In September 2016 these separate schemes were merged to form the admission avoidance and discharge service (AADS). 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 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. Between January and October 2012, Surrey County Council worked closely with health partners to introduce reliable seven days per week social care services, including earlier weekday mornings and later evenings. 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:

Managing transfers of care: an example of how a local area is working to implement system change. In Lincolnshire, a number of delays were occurring while waiting for care homes to visit the acute hospital to carry out assessments. Lincolnshire chose to address this through the introduction of 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.

Success for partners in Blackburn with Darwen has been achieved through shared recognition of a problem, and a commitment to developing a solution, and testing, revising and taking it further. This example of a local initiative forms part of our managing transfers of care resource.