A County Councils Network and Newton Research Programme
A new HomeFirst model of intermediate care in Leeds
CASE STUDY
The HomeFirst programme Leeds Health and Care Partnership, which brings together health and care organisations in the city set out to transform the way that intermediate care is delivered. The HomeFirst programme was developed 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. The HomeFirst programme consisted of five interrelated projects which focued on maximising independence and ensuring that residents always achieve their best outcome.
The five projects were: 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 and Recovery Beds: transforming bed-based intermediate care to improve outcomes and minimise length of stay in short-term beds. System Visibility and 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.
The beauty of HomeFirst is that it has brought people together through a partnership and TeamLeeds approach to look at all the key transitional points where people move from the community to hospital, from hospital to home, and from hospital to community care beds. It feels so much more joined-up now because we have had so much commitment to doing this as a system rather than individual organisations. Sam Prince, Executive Director of Operations, Leeds Community Healthcare NHS Trust
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Spotlight On: System visibility project Before the HomeFirst programme, system partners in Leeds regularly met to discuss system performance, but the lack of a unified data source meant these meetings were often inefficient and unfocused. Each partner organisation produced a lot of data, but without a single version of the truth, efforts were duplicated, and trust was eroded. Leeds needed a way to consolidate their data and a leadership model to ensure decisions were evidence-based at every stage. The introduction of the system visibility dashboard addressed this need by bringing existing data into a single, regularly updated platform. This dashboard supports decision-making at all levels, providing patient-identifiable data for joint case management at the team level and highlighting areas needing additional support at the service and system levels. This tool enables partner organisations to review data collectively and take coordinated action to resolve issues. For the first time, heads of service from all health and care organisations in Leeds can effectively review system pressures and delays, allowing for timely, cross-organisational actions to relieve pressure before it escalates. The team has been able to identify the hidden delays further down the system which were often driving some of the delays to discharge, which would otherwise go unnoticed. The System Visibility tool and Active Leadership approach has transformed how Leeds manages system performance, fostering collaboration and enabling more effective, data- driven decision-making.
OUTCOMES
The HomeFirst programme has seen many positive outcomes, but most importantly, residents of Leeds are receiving highly effective services and are supported in achieving significantly improved outcomes. The programme is having the following impact on outcomes across intermediate care in Leeds: 169 more people able to go home after their time in intermediate care rather than a long- term bedded setting each year 8.2 day reduction in the average length of stay in short-term beds 421 more people going directly home after their stay in hospital each year 786 fewer adults admitted to hospital each year 31% reduction in length of stay for complex patients with no current reason to reside 522 additional people benefitting from reablement each year The effectiveness of the home-based reablement offer has increased by 8% (in terms of long-term home care hours following the service), with a 19% increase in the proportion of people leaving the service fully independent 33% decrease in readmission rates after receiving home-based reablement This performance translates to £23.7m per annum of equivalent financial benefit to the system. These benefits are spread across system partners and are a combination of cost- out, future cost avoidance, or investment in quality. There is more to do to deliver the full vision of the programme and ensure that Leeds Health and Care Partnership is able to support the changing needs of the population in years to come, but the impact and approach of HomeFirst delivers a strong foundation to build from.
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CONTACT US
Ben Garside Partner
E: ben.garside@newtonimpact.com
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