Some of the most vulnerable people in Leeds are benefiting from a pioneering approach to reduce or avoid hospital admission and make it safer and easier for people to go or stay at home.
Despite being medically fit for discharge, many people are unable to safely leave hospital because of the lack of timely and appropriate support in the community. This is a nationwide challenge, with an average of 12,300 such people a day in hospital beds across the country.
The impact on people’s long-term recovery and ability to regain independence, and the cost to health and social care is significant – Leeds-hailing programme, HomeFirst, uses digital tools to tackle this.
The HomeFirst Programme is a partnership between health and care organisations in Leeds, working with delivery partner Newton.
It was one of five NHS ‘frontrunner’ programmes and focuses on transforming intermediate care – that is, care for people who have been in hospital or who are at risk of going into hospital. Typically, they need support in taking medicines, getting dressed, making meals, regaining confidence to walk and living independently again.
The programme is hailed as a national exemplar for its innovative approach. This involves using data and digital tools to help achieve outstanding results, with the potential for embedding long-term, systemwide change.
HomeFirst brings together GPs, nurses, therapists, social care and NHS Continuing Healthcare (CHC) practitioners into a single integrated team by offering a coordinated approach to care delivery at point of discharge.
To do this, it puts innovative processes and procedures into place to ensure service users are effectively tracked and assessments coordinated, and that assurance systems are robust to maintain quality control. This includes:
As a result of the programme’s first 18 months of work, based on October 2024’s figures, over 1,200 fewer adults were admitted to hospital. For those admitted to hospital, length of stay for people requiring support on discharge was cut by 17% and more than 400 more people went directly home without needing a bed in an intermediate care setting.
These figures represent a suite of measurable improvements which have lasting potential thanks to the blueprint for systemwide change HomeFirst has created.
Megan Rowlands, Programme Director, says:
“These are some of the most vulnerable people in our communities, many of whom are older people and have multiple long-term health conditions.
“The number of people aged over 80 is forecast to increase by 25% by 2035 whilst the number of people with four or more multiple long-term conditions is forecast to double by 2035. So, to develop sustainable, more effective care that better supports people’s wellbeing and independence, it’s been crucial that we took a deep dive into the issue and better understand what needed to change and how. That’s what HomeFirst is about.”
Analysing people and carer’s feedback, along with health and care data about this population group via the Leeds Data Model, the HomeFirst team were able to establish specific goals and measurable indicators of success, learning as they went.
Sean Gill, Programme Lead, says:
“Partnership working is a huge strength of the Leeds system, and this has really maximised the benefits that have come from improving visibility and developing a culture of data-led decision making.”
Digital tools have been a core part of informing what needed to change and how. For example, the programme team worked alongside staff to design a new app which is now used by all support workers on their digital devices to feedback information following every visit to a patient.
This has enabled the service to make real-time care decisions which are personalised to that individual, ensuring more efficient use of resources while improving support for more people at home.
As part of the research, people and carers said that one of the top areas for improvement was communication and coordination, particularly between different staff groups and organisations.
To help address this, the team developed a Recovery Plan. This uses existing digital functionality to provide a shared read/write plan where staff can ensure that what matters to the person is captured, along with plans, actions and updates.
The Recovery Plan has initially been rolled out across hospital wards to support teams working together on discharging people. It is already enabling people to leave hospital more quickly and smoothly once they have completed their hospital care. That means staff have more time to focus on working with people rather than looking for information. The team are now considering how this approach can be extended to other areas.
In turn, this data and these insights have fed into a unique ‘system visibility data dashboard’.
With equivalent financial benefit for the health and care system in Leeds estimated at £17 million to £23 million a year, the implications of HomeFirst are transformational. As the current phase of the programme concludes, the team is working to embed these improvements for the longer term.
Its success in Leeds has attracted acclaim nationally and internationally, with NHS England colleagues steering an Australian health and care delegation to visit Leeds earlier this year to learn about HomeFirst.
“We’re proud of what we’ve achieved so far, but the job isn’t done,” says Megan. “We knew it wouldn’t be a one-step journey but, because of this work, we’re confident people in Leeds are receiving a better service than before.
“In the current climate, when services are stretched and resources are more precious than ever, it’s been essential that we create change using the resources we already have.
“We’ve achieved that in the work we’ve done so far, and the collaboration across our health and care system has strengthened enormously, which bodes well for further citywide and systemwide innovation.”
The HomeFirst Programme exemplifies how innovative approaches and collaborative partnerships can transform care delivery. By leveraging data and digital tools, HomeFirst has not only enhanced the efficiency and effectiveness of intermediate care, but also laid the foundations for further change.
To read the original HomeFirst spotlight feature and to find out more about Leeds’ healthtech scene, check out the Health Innovation Leeds website.
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