The challenge Across the country, health and care systems are facing a range of challenges in the delivery of intermediate care due to rising demand, driven in part by an aging population with increasingly complex health conditions. In Autumn 2022, the Leeds Health and Care Partnership, which brings together health and care organisations in the city, commissioned Newton to conduct an initial review to help identify how the system could improve the delivery of intermediate care for the residents of Leeds. The review showed that whilst thousands of people from across Leeds were receiving great health and care, there were a number of challenges in the system related to patient flow and the transfer of people into intermediate care, which meant that individuals were not always achieving their best outcome. Impact Based on this evidence, the Leeds Health and Care Partnership, supported by Newton, set out to transform the way that intermediate care is delivered in Leeds through the HomeFirst programme, which aims to achieve a person- centred, home-first model of intermediate care that is joined up and promotes independence. By working together in a true partnership, system partners have delivered a new model of intermediate care within existing workforce, funding and organisational arrangements. Fundamental to the success of the HomeFirst programme has been building on the culture and relationships across partners in the system; embedding a culture of collaborative decision making and service delivery. As a result of the changes made, the HomeFirst programme sees more residents achieving their best outcome whilst simultaneously relieving seasonal pressures on the acute and unlocking significant financial benefit within the system. The HomeFirst programme The HomeFirst programme consists of five interrelated projects which focus on maximising independence and ensure that residents always achieve their best outcome.
The five projects are: Active Recovery at Home: redesigning the home-based intermediate care offer to maximise capacity and deliver the best outcomes for people accessing these services. Enhanced Care at Home: transforming preventive services to avoid escalations in need with a specific focus on avoidable acute hospital admissions. Rehab & Recovery Beds: transforming bed-based intermediate care to improve outcomes and minimise length of stay in short-term beds. System Visibility & Active Leadership: making use of the wealth of data in the system to produce system and service level dashboards, while establishing the right cross-partner governance to use these for effective decision-making. Transfers of Care: redesigning the discharge model to minimise discharge delays and ensure the system achieves the most independent outcomes for people leaving hospital. The new ways of working have been designed, trialled, iterated and scaled by experts including frontline staff and operational managers from across the system.
Everybody is now working together, so we’re working in the hospital together with community and primary care colleagues and with social care to ensure that we’ve got a truly integrated way of person-centred support based on need.” Phil Wood, CEO, Leeds Teaching Hospital
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