Established an integrated, co-located, team across health and social, the ‘Transfer of Care Collaborative’ (TOCC), to act as a single point of access for out of hospital care
Created a joint financing instrument for the TOCC budget to fund out-of-hospital capacity and ‘step down’ units to transition patients from acute to community
Supported team-based capability development focusing on the practical application of new lean pathways and the development of problem-solving mindsets
TN was asked by commissioners, hospital, community providers and local authorities' leaders in a health and social care system to review and transform the 'transfer of care' function (from hospital to social and community) by developing a Transfer of Care Collaborative (TOCC).
- Supporting clinical audits: Facilitated senior doctors and nurses, therapists, social workers and commissioners to review 300+ patients, evaluating the appropriateness of hospital bed use and distilling insights on clinical needs
- Evaluating capacity requirements: Grouped patients in cohorts based on clinical need, and quantified the number of ‘medical optimised’ patients not requiring an acute bed, to understand the number of bed days that could be ‘saved’ and inform community and social care capacity planning
- Developing new policies: Improved Discharge to Assess (D2A) (where ongoing care needs are assessed out of the hospital), and Medical Optimisation policies to reduce delays in patient discharges
- Implemented new collaborative ways of working: Developed Multi-Disciplinary Team (MDT) working sessions with co-located teams to develop system ownership and unblock delays in discharges, and SOPs enhancing communication between acute and community teams
