Developing a transfer of care collaborative

Transformation Nous supported leaders in a health and social system that combined commissioners, hospital, community providers, local authorities - to review and transform the 'transfer of care' (from hospital to social and community) function by developing a Transfer of Care Collaborative (TOCC)

This innovative delivery model involved establishing an integrated, co-located, team across health and social to act as a single point of access for out of hospital care.

Organised and supported two clinical audits, reviewing 300+ patients. Senior doctors and nurses, therapists, social workers and commissioners jointly evaluated the appropriate use of hospital beds and focused on deriving insights on clinical needs.

Estimated the size of the opportunity (patients not requiring an acute bed), and developed qualitative insight on the types of needs. Grouped patients in cohorts with similar needs and performed analysis to estimate the size of patient cohorts to make decisions on community and social capacity.

Developed and agreed a new set of policies:

• D2A policy, including new pathways, criteria, and capacity for Rehab, Packages of Care, Placement, and Palliative Care
• Medically Optimised (MO) policy, including a methodology to determine whether a patient is MO

Supported discussions and developed plans for joint financing

• Out of hospital capacity, D2A step down units used to care for patients in transition from acute to community
• Increased number of discharge coordinators
• Shared budget for the TOCC

Developed and implemented new ways of working and SOPs, including:

• Twice daily Multi-Disciplinary Team (MDT) working sessions with co-located teams from community health, hospital, and social care. Sessions developed system ownership for patients and unblocked delays to discharge
• Daily capacity calls between acute and community to review available capacity and create a list of priority transfers

Supported capability development focusing on teams, not just individuals, e.g.

• Application of lean D2A pathways – removing unnecessary steps, duplication, and bottlenecks
• Helped teams to introduce daily problem solving, focusing both on the process and the mindset
• Coached hospital nurses, therapists and community capacity coordinators in new ways of working