Case studies

The Leeds Health and Care Partnership includes health and care organisations from across Leeds who are working together to improve the health of people in Leeds.

This case study describes how Cheshire West and Chester Council developed a revised performance management framework (PMF) alongside its new council plan.

The health and care system in Warwickshire has maintained, and strengthened, its ‘discharge to assess’ model through the COVID-19 period by remaining aligned to its core principle of maintaining a person centred Home First approach.

To provide an equitable hospital discharge experience for residents whilst improving performance associated to delayed transfers, a bespoke Hospital Discharge Service was established in October 2017, with the use of iBCF monies to expand the council’s ‘discharge team’ located at the hospital where the greater number of admissions historically occurred. 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.

‘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.

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.

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.

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.