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:
Supported discussions and developed plans for joint financing
Developed and implemented new ways of working and SOPs, including:
Supported capability development focusing on teams, not just individuals, e.g.