Mansfield: implementing the ASSIST hospital discharge scheme

The scheme is helping to reduce discharge delays by making sure that patients have the necessary housing support when they are discharged. This example of how local areas are working to implement overall system change forms part of our managing transfers of care resource.

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The ASSIST– advocacy, sustainment, supporting independence and safeguarding team – scheme brings together teams from the district council, Nottinghamshire County Council, Sherwood Forest Hospitals NHS Foundation Trust, Mansfield and Ashfield Clinical Commissioning Group, and Nottingham Trent University.

Referrals to the ASSIST team are made by health and social care colleagues at King’s Mill Hospital in Sutton-in-Ashfield who identify patients with a housing or social care need. The team works with Mansfield District Council housing department to find solutions that enable these patients to leave hospital safely.

The scheme, which won this year’s Shared Learning Awards organised by NICE, is helping to reduce discharge delays by making sure that patients have the necessary housing support when they are discharged, which may be in the form of home adaptations or a change of accommodation that better meets their needs when they leave hospital.

Specifically, the scheme works to:

  • speed up hospital discharge and prevent hospital readmissions; providing access to a 24/7 service
  • source alternatives to residential care; using housing stock to meet local need, and prioritising the letting of existing adapted accommodation; fast-tracking repairs to properties, providing key safe installation and minor adaptations, and installing lifeline and telecare systems
  • use temporary accommodation and respite units (funded by Nottinghamshire County Council) to facilitate discharge
  • access food banks and furniture projects as needed
  • support the hospital’s emergency department ‘front door’ by engaging with people who have a social need and freeing up hospital staff to deal with emergencies • support discharged patients in the community.

A study by Nottingham Trent University and Mansfield and Ashfield CCG found clear evidence that the scheme saves the NHS £1.371 million annually by freeing up beds.

The scheme saved an average of 4.5 bed days per patient helped and this represented a saving of £936 per patient.

Since its inception in October 2014 up to January 2017, it has helped well over 2,000 patients. A video which explains the partnership aspects of the ASSIST scheme and highlights its benefits can be found at My Mansfield on Facebook.
NICE, ASSIST hospital discharge scheme in Mansfield


Michelle Turton
Housing Needs Manager
Mansfield District Council