Elderly man opening his front door, he is smiling

Transfer of care out of hospital – or discharge – is one of the Partnership’s key priorities.

Our aim is have no one in hospital who does not need to be there and to offer people the support they need in the right place at the right time.

While hospitals are vitally important for us when we need medical treatment, staying there longer than we need to can cause harm, particularly if we are older or frail. Failing to support people to return to their home also affects our ability as a health and care system to care for those most in need.

Our approach follows the national “Home First” agenda where, for most of us, “home is best” for assessment and ongoing support.

This programme of work is being overseen by the System Discharge Group. The group is co-chaired by directors of both health and social care, has a broad membership of partners including the West Yorkshire Integrated Care Board (ICB), Wakefield Council, Mid Yorkshire Hospitals NHS Trust, community health, Connexus (GP federation), provider colleagues of residential and homecare support, and the local voluntary sector.

It has four key work strands:

  • operational efficiency
  • data and intelligence
  • service redesign / commissioning
  • communications and engagement

We’ve introduced a number of changes to support patient flow through the health and care system and to help get the best outcomes for the people we work with. These changes are already showing positive results.

The latest figures show that the number of local people able to be discharged from hospital rose by 11 percent in the last six months of 2022. The monthly average number of discharges for people who no longer needed medical treatment or care at the Mid Yorkshire Hospitals NHS Trust increased from 1,879 to 2,118 – 11 percent – in the second half of 2022 compared with the first six months.

Here are some of the improvements we’ve made that are helping more people get out of hospital and back to the place they call home:

  • Development of the Integrated Transfer of Care Hub (IToCH)
    The IToCH is a multi-disciplinary hub based at Pinderfields Hospital. It is made up of staff from the hospital discharge team, adult social care, community health, housing, reablement and the voluntary sector. The hub team have been working together to streamline transfers of care from hospital since March 2022.Phase two of the development has included new multi-disciplinary triage system to support ‘pulling’ people home from hospital rather than focussing on discharging them. This has streamlined the transfer process so that referrals go directly to the right agency to support the person. This includes new partners joining the hub including teams who will consider how assistive technology can support people to stay as independent as possible at home.
  • Complex care pathway
    The complex care pathway aims to significantly reduce length of hospital stay for people living with dementia. The pathway includes training for hospital staff and residential and homecare providers, and specific beds in the community that offer further assessment out of hospital for individuals who may present with behaviours that challenge in hospital due to their disorientation. Additional, 24 hour wrap-around support will also be provided on discharge to help the person settle into their new environment. As part of the pathway development, new specialist dementia nurse and support worker posts have been created within IToCH to specifically help understand the needs of those living with dementia while they are in hospital and to enable the person to be supported in the best environment for them on discharge.
  • Joint bed coordination
    A dedicated person will oversee all intermediate care beds in the Wakefield district across both health and social care. This will maximise our resources and allow these beds to be used more flexibly at times of high pressures on the health and social care system.
  • Emergency Department admission avoidance
    A dedicated rapid response team support people getting ‘Home First’ quickly with the right support where they do not need an admission to hospital. When patients are ready to return home from a stay in hospital, the team will ensure the correct support is place to reduce the risk of re-admission.
  • Additional Discharge to Assess (D2A) commissioned beds
    We have bought an extra 29 Discharge to Assess (D2A) beds. These additional beds will allow people who cannot go straight home to access a short-stay bed in a residential or nursing home where they can recuperate, recover and have an assessment of their ongoing needs. The beds will be supported by both health and social care staff who will be working closely with provider colleagues to ensure there is flow both into and out of the beds.
  • Change to commissioning of homecare by Wakefield Council
    Changes have been made to the way social workers are able to access support for people. This has seen a significant rise in the numbers of home care providers that they are able to access on discharge from hospital and means that this support can now be accessed very quickly, directly from hospital. This is significantly reducing the length of time people wait for home care.
  • Voluntary sector discharge model
    Age UK Wakefield District is now leading on a joint approach to supporting people after discharge. This includes helping them to get home and settled in, helping with shopping and linking in with local services.
  • Listening to patients’ feedback
    Understanding people’s experiences is really important to us. Healthwatch Wakefield is working with us to make telephone contact with people who have had recent experience of discharge to get real time feedback about their experience. This information will then be fed into the System Discharge Group to identify and address any themes from the feedback.
  • Quality Discharge Group
    A Quality Discharge Group has been set up to work more closely with local health and care providers around their experience of transfers of care. Processes are being put in place to allow providers to raise issues as they arise which will be resolved through the Integrated Transfer of Care Hub. Where themes are picked up, changes to processes will be made with provider colleagues to ensure that communication lines are clear and effective and make sure that discharges are as streamlined as possible.
  • Night Response Service
    A new Night Response and Turning service will provide extra support to people who need help overnight. The service will include help ‘turning’ people at risk of pressure ulcers or hospital admission to help them to stay at home. This service will also provide overnight support to the dementia pathway.
  • Making intermediate care services more joined up
    The Wakefield Integrated Care Team (ICT) and Wakefield Council Reablement service have worked together to provide more joined up support. This new model will see care resource shared across the two teams, which will provide increased capacity to get people home from hospital. Additional funding has also been given for 10 additional staff for the ICT to further support capacity. The new model will go live soon.
  • Work as One
    A programme of work called ‘Work as One’ was introduced at the Mid Yorkshire Hospitals NHS Trust in October 2022. Work as One concentrates on transfer processes within the hospital and ensures that people are clear about why they are in hospital, what they are being treated for and what their discharge plans are. Focus is also being given to earlier referral to the IToCH for those who need support, Board Rounds to progress transfers, clear expectations about flow from the emergency department and for discharge and earlier preparation of discharge documents and medication.
  • Criteria-led discharge
    Criteria-led discharge is being introduced within the Mid Yorkshire Hospitals NHS Trust so that people are able to leave hospital as soon as their condition has improved to agreed criteria, for example when their blood results are at a certain level. This means that a person’s transfer out of hospital is not delayed by waiting for a medical review where this is not medically necessary.


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