More patients are experiencing delayed discharges from hospitals, but integrated care boards (ICBs) are working with system partners to develop new and innovative ways to address this. In this fourth and final case study, Kathy Oxtoby reports on how Leeds Health and Care Partnership is approaching this longstanding issue with their person-centred HomeFirst model.
Work is taking place across the West Yorkshire Health and Care Partnership integrated care system (ICS) to help address patient discharge issues.
A person-centred ‘home-first’ model of intermediate care across Leeds that is joined up and promotes independence is the vision of the HomeFirst programme run by Leeds Health and Care Partnership – one of the five places under the ICS.
The programme was prompted by the need to improve the delivery of intermediate care in Leeds. ‘As partners working in Leeds, we knew that by working together we could support people better and that they were not always getting the best possible outcomes,’ says Megan Rowlands, programme director for the Leeds HomeFirst programme.
In Autumn 2022, more than 200 people across the Leeds system worked together to complete a system-wide diagnostic review of outcomes from the intermediate care available and the interaction of acute, community and social care services.
The diagnostic work involved the detailed review of over 220 cases, data analysis of more than 50,000 patient journeys, the views of over 600 patients, service users, families and carers, and input from eight organisations across Leeds.
The findings from the diagnostic review included that too many people were spending more time in hospital than they needed to or could have avoided hospital altogether.
The review also found that short-term care in the community was provided across many different services and that people also spent more time than they needed to in many of these services. Capacity challenges in these services meant many people who could benefit from intermediate care were going straight into long-term care with lower levels of independence than they might otherwise have achieved.
There was a relatively high use of bed-based care, and more people could have been supported to stay at home with a greater level of independence. And many older people could have reduced or avoided the deconditioning that has an impact on their independence and long-term care needs, the review found.
To help address these issues, five core projects have been established within the HomeFirst programme, starting in May 2023.
- Active Recovery at Home has involved redesigning the home-based intermediate care offer to maximise capacity and deliver the best outcomes for people accessing these services
- Enhanced Care at Home is about transforming preventive services to avoid escalations in need with a specific focus on avoidable acute admissions
- Rehab and Recovery Beds has involved transforming bed-based intermediate care to improve outcomes and minimise length of stay in short-term beds
- Transfers of Care has involved redesigning the discharge model to minimise discharge delays and ensure the most independent outcomes for people leaving hospital
- And System Visibility and Active Leadership is about making use of the data in the system to produce system and service-level dashboards while establishing the right cross-partner governance to make effective decisions using these.
Within each project, design groups of system experts have come together to shape the changes required. These range from progress changes, digital tools and new ways of working through to new models of service delivery.
These changes have then been piloted and iterated with individual teams, using evidence gathered on the performance of key measures, staff feedback and patient/service user feedback, before being scaled up across the system.
As of June 2024, 100 more people were able to go home after their time in intermediate care instead of a long-term bedded care per year. There was a 7.3 day reduction in the average length of stay in short-term beds. Some 478 additional people have benefitted from reablement each year. There are 422 more people going directly home each year after their stay in hospital instead of a bedded setting. And 1,082 fewer adults are being admitted to hospital each year.
‘Supporting more people to go home rather than into long-term residential care is better for people and often what people want. People are more independent and supported in their own environment,’ says Ms Rowlands. The HomeFirst approach ‘allows us to use our resources more effectively, and hospital beds are freed up sooner’, she says.
A huge enabler to the success of the programme has been building on the culture and relationships across all partners in the system, including healthcare organisations, social care providers and third sector organisations. ‘It’s been a real team effort,’ says Ms Rowlands. ‘All of our partners – not just at executive level but also those involved in delivering services – have been working together to deliver the programme,’ she says.
She says similar initiatives are happening across West Yorkshire to help address similar challenges with patient discharge and supporting people at home.
Supporting HomeFirst pathways
One of the initiatives that complements HomeFirst is the Carers Hospital Discharge Toolkit.
NHS West Yorkshire ICB’s unpaid carers programme has produced the toolkit and resources to support NHS trusts in carrying out their statutory duty to involve unpaid carers in discharge pathways and to improve unpaid carers’ experiences of discharge through increased identification, support, signposting, and referral. The toolkit has been co-produced with NHS staff, voluntary sector carer organisations and people with lived experience.
The toolkit also supports reducing health inequalities for Core20PLUS5 populations with its co-production and engagement from ethnically diverse carers and young carers. Post-launch evaluation of the toolkit has already shown that 80% of carers stated they were more involved in conversations about discharge, and as a result, 71% of carers felt more prepared for the discharge of their family member they supported.
A carer who was involved in developing the toolkit says: ‘I really welcome this resource. It’s so important that carers are kept informed and involved when those they care for are in hospital, especially when they’re due to be discharged. They may leave hospital needing additional care or new equipment, for example, so their carer may need advice or extra support. They may not even have thought of themselves as carers previously, or they may be new to caring, so making sure they’re aware of services that can help is vital.’
‘Collaboration is pivotal in addressing patient discharge challenges across West Yorkshire,’ says Helen Lewis, director of pathway integration for the Leeds Health and Care Partnership.
‘It’s great that the HomeFirst model we have introduced in Leeds has already made a difference. Providing the right care at home and better ways of working on the wards means more people are getting out of hospital sooner into places where they can continue their recovery safely and enhance their longer-term wellbeing. We are also improving our alternatives to admission, supporting people to stay at home rather than be admitted to a hospital bed,’ she says.
‘Although we recognise the ongoing challenges in workforce and funding, by implementing a person-centred, HomeFirst model and enhancing intermediate care services in Leeds, we are not only improving patient outcomes but also promoting greater independence and reducing unnecessary days in hospital. We are seeing similar initiatives across West Yorkshire, reflecting our shared commitment to delivering high-quality, sustainable care for our communities.’
Further analysis and case studies
Read more about tackling delayed hospital discharge and improving patient flow in this analysis, and discover some of the other inspirational work being done across England in the first three case studies of this series:
- Case study 1: Virtual ward and Quick Start initiatives from Central London Community Healthcare NHS Trust
- Case study 2: Improving the discharge lounge at the Royal Free London NHS Foundation Trust
- Case study 3: A home first ethos from Mid and South Essex ICB and Mid and South Essex NHS Foundation Trust
This case study was originally published by our sister publication Healthcare Leader.
