Leeds’ HomeFirst Programme brought partners together across health, care, the third sector and local communities to improve intermediate care, strengthen system flow and help more people recover closer to home.
Overview
The HomeFirst Programme was established in 2022 with the primary aim to improve outcomes for Leeds residents accessing intermediate care, to improve staff experience and to make better use of our collective resources.
Action
The programme was made up of 5 independent projects, all relying on strong working relationships across system partners, including third-sector organisations.
- Active recovery at home (short-term community rehabilitation and reablement, both for step-up and step-down care)
- Enhanced care at home (improving urgent community response and avoidable hospital admissions)
- Community rehabilitation and recovery beds (short-term community bed based rehabilitation, both for step-up and step-down care)
- Transfers of care (improving processes to enable people to move on to their next place of care)
- System visibility and active leadership
A key building block for developing these relationships and team approach was the creation of a system-wide reporting suite and access to a common analytics dashboard, which all partners trust to provide a single truth of system flow.
These tools empower leadership and improvement groups to understand the biggest blocks to capacity and outcomes and where to direct their support.
The programme invested in short-term resource: financial investment for external delivery partner and dedicated programme capacity, and in-kind alignment of colleagues from the Leeds system, to support the work over an 18 month period. Senior executive leadership was critical to securing engagement across the health and care partnership to enable delivery of programme outcomes. See: Leeds system visibility approach for further detail.
In 2025 the original programme concluded. The Leeds Health and Care Partnership recognise that further work is needed to support sustainable improvement in intermediate care. This is being led through a refreshed partnership programme as part of Neighbourhood Health development. This brings together partners from the local authority, NHS, third sector, primary care, and independent providers, working alongside local residents to develop neighbourhood health and care services that work together to proactively prevent health and wellbeing deterioration, with the goal of enabling more people to live well and independently and be supported in their own homes.
The aims of Phase 2 of the programme are:
- Implementing a neighbourhood proactive care model that works with people and families to improve health outcomes for those most at risk (5-7% people living with frailty and long-term conditions). Developing our approach to Creating the Conditions for this way of working, contributing to the Neighbourhood Health model.
- Building on HomeFirst and continue to develop our intermediate care offer so that people spend less time away from their own bed, can be supported closer to home, and enable smooth and timely transfers from hospital and community beds.
- Undertaking a Prevention Diagnostic that aims to promote independence and avoid delay or reduce people’s needs for care and support services and ensure that we improve our approach to targeting people that will benefit most.
Outcomes
The following outlines the benefit that Phase 1 had on people’s outcomes as at March 2025:
- 899 people avoiding a hospital admission each year.
- A 31% reduction in discharge delays for people requiring ongoing support after their stay in hospital.
- 470 people supported to return home after their stay in hospital instead of being discharged to a bedded setting each year.
- A reduction of 8.1 days in the average length of stay spent by people admitted to our short-term beds.
- 565 additional people able to benefit from reablement each year, supported to regain their independence at home, following a stay in hospital.
- 152 people per year able to return to their own home following a stay in a short-term bed, instead of going into a long-term residential placement.
The objectives of Phase 2 are:
- Better outcomes and experience for people and families
- Better experience for staff
- Better meds optimisation
- Better Continuity of Care
- Reduce unplanned care activity across our partnership
- Reduce utilisation of No Reason to Reside bed days
- Improved use of shared resources
The intermediate care work is targeting further improvements to release approx. 44,000 hospital bed days by March 2028, whilst for every 1000 people supported with a proactive care approach, we can potentially prevent 1309 community healthcare contacts, 5760 GP appointments, and 118 A&E attendances.
“At the end of the day, you can’t beat your own bed and your own environment”
Brian, Leeds resident supported by Rehab and Recovery Beds.
For further information see: Leeds HomeFirst - transforming community care - Leeds Health and Care Partnership
Peers to Contact HomeFirst Programme - [email protected]