Partnership with HomeLink saves 20,000 bed days at James Paget Hospital

Thanks to a partnership with HomeLink Healthcare, The James Paget University Hospital NHS Foundation Trust has freed up nearly 20,000 bed days since they started working together four years ago. The service, known as Paget at Home, creates an additional ward of capacity every day, by providing treatment and care at home to patients who would otherwise have remained in hospital. The operational headroom created contributes to productivity benefits while the bed days are costing less than half the equivalent in-hospital care.

"Pro-active lead, excellent engagement with Trust colleagues and escalating concerns"
- James Paget Client Survey

The situation

Like almost all acute hospitals The James Paget was experiencing extreme capacity issues when they first commissioned our services back in March 2020. Fast forward to the end of 2023 and hospital bed capacity was 88%. This compared favourably to an average across all NHS hospitals of 90%, thanks in part to Paget at Home.

The solution

Paget at Home started as an Early Supported Discharge service which included clinical care at home and Bridging Packages of Care. It has developed over four years to cover a range of pathways including supporting the Virtual Ward, IV Therapy, Discharge to Assess and Reablement.

How does it work?

An on-site team pro-actively identify patients who are medically optimised or no longer meet the criteria to reside and enable same-day transfer / discharge home. Home based wrap-around care is provided by a HomeLink Healthcare multi-disciplinary team. The on-site team do the heavy lifting managing the on-going care, co-ordinating with consultants, referrers and community providers, minimising the impact on hospital staff.  The service is supported by a 24/7 on-call service.

As a clinician-led organisation, a commitment to quality care is at the heart of everything we do. For each new pathway HomeLink Healthcare carry out a feasibility assessment using hospital data. Clinical governance is co-produced, and pathways are rapidly prototyped, evaluated and rolled out, using technology as an enabler where appropriate. A comprehensive suite of KPIs is implemented, and real-time data allows the team to identify best practice quickly and apply corrective actions as necessary.

Services are commissioned using the NHS SBS Patient Discharge and Mental Health Step Down Beds Services Framework Agreement. Using the Framework means that the time to contract is shortened significantly compared to a full tender. This saves significant time and money and enables us to fully mobilise new services through a ‘test and learn’ phase to full ramp in 4-12 weeks.

"Excellent team and service, so happy I can be treated in my own home"
- Patient

The results

Increased capacity and improved patient flow: Over the last four years Paget at Home has supported over 1,000 patients and released over 20,000 bed days, saving an average of 20 bed days every day. This is the equivalent of almost a whole hospital ward. With a capacity of around 500 in-patient beds, these 20 ‘at home beds’ effectively increase hospital capacity by four percent.

Better patient outcomes: Patients reported, on average, a 21 percent improvement in clinical outcomes (EQ-5D-5L) by the end of their treatment. 99 percent also said they would recommend HomeLink/Paget at Home to Friends and Family. By supporting patients across a largely rural area our service also address inequalities in access to care.

Better patient outcomes

Cost effective: In 2022, James Paget calculated the average cost per hospital bed to be £450. The cost of our Hospital at Home services are currently under £200 per bed day. Even without factoring a cost increase, this is a 55 percent cost saving.

Implications for the future

Patients: Paget at Home and other HomeLink Healthcare Hospital at Home models ensure that patients spend much less time in hospital which reduces the risk of infections, deconditioning and depression. By being discharged as soon as they are medically optimised or medically fit, and starting rehabilitation immediately, they also have much better outcomes. Patients much prefer being treated in the comfort of their own homes and, as a result of all these factors, they are much more likely to return to their pre-hospital level of independence. Patients are less likely to be re-admitted into hospital and will need reduced ongoing care.

Patient flow: Patients needing complex treatments or multi-disciplinary care often remain in hospital for far longer than they need to. A recent study found that the average length of stay in hospital was 34.8% longer in 2022/23 compared to 2019/20*. HomeLink Healthcare’s feasibility assessments often reveal around a ward worth of patients across the hospital that could complete their recovery at home, with the right Hospital at Home provision in place.

If every hospital in the country could create an additional 4% capacity, as The James Paget has done, this could be used to reduce the occupancy levels from 90% to 86% (85% is widely considered the risk threshold).

Sustainable additional capacity: If hospitals are to tackle increasing demand on Urgent and Emergency Departments, growing elective waiting lists and pressure on GPs they either need to increase hospital capacity (requiring more staff and additional wards) or treat more people at home.

As HomeLink Healthcare bring our own multi-disciplinary staff team, this avoids the recruitment challenges associated with resourcing additional capacity. This additional capacity, along with lower occupancy rates enables existing healthcare staff to focus on core delivery and allows time to plan for new patients and longer-term care.

Cost-savings: When occupancy levels are optimised** the cost of hospital at home services are significantly lower than the equivalent in-patient care. Improved patient outcomes mean smaller ongoing care packages, which are easier to source and lower in cost. The costs of building new hospital wards are also avoided.

Key stats (March 2020 – Feb 2024)

  • Over 1,000 patients have been treated at home
  • Patients spend on average 20 days fewer in hospital.
  • Patients reported an average 21% improvement in clinical outcomes
  • The service costs 45% compared to in-patient care
  • 99% of patients would highly recommend the service
  • 100% of client contacts said they would recommend us
  • SBS Framework allows new pathways to be mobilised in as little as 4 weeks

About HomeLink Healthcare

HomeLink Healthcare have been delivering Hospital at Home services since 2016 and provide a solution for the future. We deliver system benefits for ICBs, Trusts and the Community. Our services improve patient outcomes, improve patient flow, reduce waiting lists and save costs. In our recent survey 100% of client contacts said they would recommend us.

HomeLink Healthcare is a named supplier on the NHS SBS Patient Discharge and Mental Health Step Down Beds Services Framework Agreement. By using the framework, you can contract with us directly and we can get a new service up and running in around 12 weeks.

To discuss how HomeLink Healthcare could help your organisation, or to request a free Feasibility Assessment please get in touch.

Call 020 3137 5310 or email


* Newton / CCH report Finding a way home, November 2023

** HomeLink Healthcare virtual wards have a 97% occupancy rate compared to 70% across the NHS (Jan 2024)

Shortlisted for a Chief Allied Health Professions Officer (CAHPO) award

South East London AHP TeamHomeLink Healthcare have been shortlisted for a Chief Allied Health Professions Officer (CAHPO) award for their work in partnership with Lewisham Adult Therapy Team (LATT). The service saw the waiting list of 203 reduce by 85 per cent to 30 in an 18-week period. Not only that, 69 per cent of patients were seen within three days and improved patient outcomes were seen across the board.  

In October 2021 Allied Health Professional (AHP) Leads from the South East London joined forces with AHP Leads from HomeLink Healthcare to provide a collaborative approach to addressing the increasing demands on the community physiotherapy service for patients residing in the South East London regions of Lambeth, Southwark and Lewisham.  

The AHP Team drove innovation and change in the creation and implementation of a new pathway that addresses both the NHSE/I Long Term Plan and commitments to AHPs into Action. The results were increased physiotherapy capacity in the community; improved patient flow; and better patient outcomes and experience. 

The challenge 

The challenges identified by the AHP Team were as follows: 

  • The LATT therapy leads reported an increase in demand from referrals for patients requiring community physiotherapy.  
  • They cited workforce concerns preventing them from meeting their referral demands along with an increase in the use of agency staff thereby driving up costs and potentially reducing quality and effectiveness. 
  • LATT were experiencing an increase in staff burn out, sickness and challenges balancing annual leave and staff training. 
  • LATT reported a waiting list of 203 patients, with patients waiting more than six months for a therapy review. 
  • Concerns were raised that patients were being admitted to hospital on account of not receiving timely physiotherapy support to maintain them safely in their own homes. 
  • The patient experience was poor due to increased waiting times for therapy input. 

Aims, outcomes, and ways of working to overcome potential barriers 


AHP-logoA set of SMART aims for the pathway were co-created to improve patient flow and physiotherapy capacity for patients living in the Lambeth, Southwark and  Lewisham localities. 

  • Provide a responsive physiotherapy service that delivers efficient and effective  patient centred physiotherapy treatments to maintain them safely at home. 
  • Reduce waiting list of community physiotherapy. Prior to the service, 203 patients were awaiting therapy. 
  • Improve patient outcomes by increasing mobility and functional independence. There were no standard clinical outcomes in circulation. 


  • A shared vision of quality improvement across all pathways made it possible to mobilise the pathway in just 4 weeks.
  • 69 percent* of patients were able to be seen within three days of (non-urgent) referral (*based on patient choice). 
  • The waiting list was reduced by 85.2% to just 30 patients in just 18 weeks. 
  • Positive outcomes in mBarthel and EQ-5D-5L measures.   
    • mBarthel increased from 76.5 to 87 
    • Self-reported health state (VAS) increased from 54.4 to 67.6 
    • Self-reported EQ-5D-5L figures improved in all dimensions (note a decreasing score is an improvement) 

EQ 5D 5L

  • Quality improvement was delivered and measured with data regularly shared by the AHP Team to support wider MDT collaboration. These outcome measures are now adopted as standard within SEL.  
  • As a result of shared learnings 4x as many patients are benefitting from the new pathway in South East London. 
  • The service has spread across the System. From Lambeth and Southwark, the model has been reused in Lewisham, Bromley and Woolwich with learnings shared in other ICSs. 

How did we do this?

  • AHPs worked collaboratively. Regular review meetings were held to ensure quality and safety. 
  • An operational manual was co-produced with wider MDT to ensure effective and efficient governance. 
  • We agreed patient specific outcome measures in order demonstrate quality improvements. 
  • Wider system partners were involved in order to increase shared learning practices and collaboration to safely deliver 240 visits per week 

Transferable lessons learned:

  • Workforce retention and recruitment strategies are essential to ensure longevity to new services. This pathway enabled a 66% increase in capacity for staffing which allowed teams to take annual leave and manage COVID-19 isolations whilst providing continuation of care to patients.  
  • Involving Consultant bodies and wider system partners from the outset is essential to optimise referral and discharge processes. 
  • Being comfortable having open and honest conversations with colleagues for the benefit of the patient has enabled improved outcomes. 
  • Regular knowledge-sharing and reporting are vital for optimising patient outcomes. 
  • Ensure the whole AHP/MDT team is involved in the journey, so the service is driven by those who deliver it. Recognising the value of different knowledge and skills that staff of all levels can add. 

Adeola Telesford, Highly Specialist Rehabilitation Occupational Therapist from Enabling Services, Lewisham and Greenwich NHS Trust commented:

“I am truly pleased with the professional relationship/rapport we have built because it has enhanced our regular verbal and written feedback on cases.

I am particularly pleased by the fact your service has been able to visit patients in a timely manner (within 24-48hours of receiving the referral) and to carry out pre-planned joint visits with me. Timely intervention, which I have found with a number of cases, made a significant positive impact on the SMART goals that were set for each patient.

It was refreshing if not amazing to see how the combined intervention of PT and OT input complimented each other. Your service input proves the validity in having PT and OT working alongside each other in a service of this nature when working towards a time frame of maximum 6 week interventions. I look forward to continued working with you”.

Collaboration with four NHS organisations frees up two hospital wards every day

HomeLink Healthcare has been working across Norfolk & Waveney ICS alongside multiple NHS organisations to respond to exceptional capacity challenges.

"HomeLink gave us the ability to quickly respond to demand, flex up and down, and were invaluable in enabling us to meet varying complexity of needs”
- NHS Trust Chief Operating Officer

The partnership began in 2019 with Norfolk and Norwich University Hospital (NNUH). Today we also work with James Paget University Hospital, The Queen Elizabeth Hospital King’s Lynn, and Norfolk & Waveney ICB.

Hospital at Home services are delivered through a number of pathways: Virtual Wards, Reablement, Early Supported Discharge, and Discharge to Assess. Some pathways include patient monitoring. We also provide Bridging
Packages of Care.

This testbed for pan-ICS work in collaboration with an independent sector provider has been very successful. Services are rated excellent by patients, provide measurable system benefits and improved patient outcomes. Services are also delivered at 45% of the equivalent in-patient cost.

The scope and scale of the collaboration continues to expand across the ICS. Findings have been shared and used to inform models of care and to support delivery of NHS strategy and plans.

Setting the scene

"HomeLink Healthcare has an ongoing flexible collaborative approach; high-quality service provision with robust governance and transparent data and reporting”
- NHS Trust feedback

The Norfolk & Waveney Integrated Care System (ICS) covers a largely rural area in the East of England.

The widely dispersed population and long travel times, on mainly country roads, creates challenges in providing consistent community and home-based care.

In addition, the relatively isolated location makes it hard to attract and retain sufficient numbers of community nurses, physiotherapists and healthcare assistants.

Gaps in access to community care led to delays in discharging patients from hospital, with the inevitable impact on emergency admissions and electives.

In 2019 it was decided to engage with a specialist Hospital at Home service provider, HomeLink Healthcare, to provide pathways for patients who had no need to remain in hospital.

In common with many systems, NNUH faced a longstanding need to create additional acute capacity that became more severe in 2020.

The benefits of the new services were closely monitored.

Key achievements

• A unique pan-ICS collaboration with the independent sector

• The partnership has saved 45,000 bed days (Jan 19 – Apr 23)

• Services were delivered at 45% of the in-patient cost (James Paget University Hospital, Jan 21- Aug 22)

• 17% improvement in self-reported clinical outcome measures (EQ-5D-5L Jan 19 – Feb 23)

• Today the service frees up the equivalent of two hospital wards every day (56 hospital beds)

• Over 99% of patients would highly recommend us (patients scoring us 8+ out of 10)

• Findings have been shared across the ICS and with NHS England

• The partnership was shortlisted for an HSJ partnership award in 2023

The collaborative approach

Initially, a ‘test and learn’ pilot was conducted at NNUH with the financial, patient and system benefits evaluation leading to conversations across the other acute hospitals, community providers, and Norfolk & Waveney ICS.

A Virtual Ward was developed at NNUH in 2019 and findings were used to improve subsequent service development.

Since 2020, we have worked with a team from the Trusts and ICB to design and create additional Hospital at Home services including treating patients with more complex needs. We have also provided short term wrap-around support to frail patients, to reduce hospital attendance, and to support independence. Taking a safety-first approach, we ensure that governance is paramount and that KPIs are built into the system.

Services were rapidly prototyped, evaluated and rolled out, using technology as an enabler where appropriate. A comprehensive suite of KPIs was implemented and real-time data allows the system to identify best practice quickly and apply this across the ICS.

HomeLink Healthcare provided a flexible regional workforce with a good understanding of the local geography. We worked with our NHS colleagues as one team and acted as a force multiplier in a hard-to-recruit region. The result was that capacity was always maintained and inequality in access to care was reduced.

Patients rate the service as ‘excellent’, and outcomes have been impressive. We use the EQ-5D-5L ‘self-reported clinical outcome measurement‘. We saw an average improvement of 17% between January 2019 and May 2023. Patients also demonstrated a positive improvement in the following five domains: mobility; self-care; usual activities; pain/discomfort; and anxiety and depression. We use an ongoing flexible ‘test and learn’ approach which ensures robust governance and continual service improvement. Operations manuals were co-designed specifically for each service and reduced service duplication saves the NHS time and money. New services can now be mobilised within as little as four weeks.

System benefits & the future

As four NHS organisations and an independent provider, we were combined early adopters of Hospital at Home services. We have worked from the start to share benefits across the ICS. The collaboration has shown how pan-ICS contracting results in better value for the NHS and an excellent patient experience and outcomes.

The scope and scale of the collaboration continues to expand across the ICS. Findings have been shared with NHS England, and Virtual Ward models align with and support NHS strategy and plans.

Get in touch 

To speak to a member of our team about our services, call us on (020) 3137 5370 or contact us. You can tell us about your situation, and we can tell you more about our experience and how we might be able to help you. 

Joined-up work demonstrates compassion and helps avoid two hospital admissions

HomeLink Healthcare accommodated a couple’s return to their own property following a hospital stay. Whilst providing a package of care for both parties, and IV treatment for the wife, we supported the couple through multiple additional issues which were not initially identified.

Whilst the multi-disciplinary team were constructing a longer-term plan, the HomeLink team recognised where and how the couple were struggling and prevented two hospital re-admissions.   

Aneta, who is her husband Jim’s main carer had been in James Paget University Hospital receiving treatment for an infection and fatigue. When Jim and Aneta were discharged from hospital on 30th October 2023, HomeLink Healthcare were asked to provide Aneta with a once-a-day package of care as well as IV therapy for six weeks. Jim also required a twice-a-day package of care. 

On the first visit HomeLink staff identified that both patients were struggling being at home and that Aneta had pain that was poorly controlled. Aneta’s pain was distressing Jim, which in turn upset his wife. The situation required more input that first expected.  

On 2nd November the couple were waiting social worker allocation and a concern with safeguarding was also raised.  The visiting HomeLink nurse went to the patient’s medical practice, raised concerns with the GP and organised a complex needs assessment joint visit with the GP for both parties, concentrating on pain management for Aneta. HomeLink staff stayed for longer than the allotted time with the couple offering support, caring and liaising with the multi-disciplinary team to resolve the concerns. It was decided that extra visits would be allocated to the patients to ensure they were safe and supported. 

On 3rd November Aneta had developed a urinary retention due to the pain and required re-catheterisation by the community nurses.  The medical consultant at James Paget University Hospital asked for our team to continue to monitor for mobility decline. An urgent MRI was booked.  

On 10th November following daily contact with visiting staff, the HomeLink Clinical Lead visited the patients at home with their GP and Social Worker.  Aneta’s pain management was reviewed and changed to a transdermal pain patch. The Social Worker suggested the use of respite care for the couple to allow the wife to recuperate whilst not needing to care for her husband.  

HomeLink continued to support the couple until respite care was sourced, reducing the number of visits required over time.  

This story demonstrates HomeLink Healthcare’s commitment to providing a safe, effective, caring, responsive and well-led service. The staff involved demonstrated our values of Compassion; Commitment to Quality Care and Collaboration. It also shows how providing excellent multi-disciplinary support through one provider enhances the patient experience and provides system benefits to the NHS through admission avoidance which in turn improves hospital flow and saves the NHS money. 

Find out more about the features of a HomeLink Healthcare Hospital at Home service 

Get in touch 

To speak to a member of our team about our services, call us on (020) 3137 5370 or contact us. You can tell us about your situation, and we can tell you more about our experience and how we might be able to help you. 

Case study: Feasibility assessment

A recent feasibility assessment concluded that implementing Hospital at Home services would free up significant numbers of inpatient beds.

In September 2023 HomeLink Healthcare’s experienced clinicians spent two days with an NHS Trust. We discussed the Trust’s current challenges, and ‘walked the wards’ to identify opportunities to discharge patients. We carried out a detailed feasibility assessment across seven wards  in surgery and medicine. These wards accommodated around a third of the hospital’s 700 beds.

The potential impact of implementing Hospital at Home services

A Virtual Ward would free up a full ward of beds in the hospital.

Virtual Ward:

Our team identified 25 patients from different specialties that could have been treated at home on a Virtual Ward.

Bridging Packages of Care:

HomeLink Healthcare Bridging Packages of care would have released an additional 16 beds (or reduced the average length of stay by 4.5 day for each patient awaiting a package of care).

A further 16 patients were identified as being medically fit for discharge and were waiting to return home with a package of care. On average it was taking the Trust four to five days to arrange this care with local providers. HomeLink Healthcare respond to referrals within two hours and can facilitate a return to patients’ homes on the same or next working day.

IV Therapy:

The Trust’s OPAT team were taking patients on longer IV prescriptions, however any patient requiring short courses were kept on the ward even though they were medically stable and could be treated at home. This is causing bed blocking and could be alleviated with administration of IV therapy in the community. HomeLink Healthcare has been providing this type of service to other NHS Trusts since 2019.

Applying this across the NHS

NHS hospitals frequently run at above 95 percent bed occupancy levels which impacts on hospital flow. Our feasibility study highlights the impact that Hospital at Home services can have. HomeLink Healthcare Hospital at Home services:

  • improve patient flow as well as patient experience and outcomes.
  • typically cost half the equivalent in-hospital care (James Paget University Hospital data).
  • help hospitals avoid recruitment challenges, we bring our own staff.
  • can avoid the need for capital expenditure on new wards.

What is a feasibility assessment?

As part of our consultative process, HomeLink Healthcare offer prospective clients a no-obligation, free feasibility assessment. The assessment provides a snapshot, at a given time, of the patients that could be treated at home. As a result, it provides a good indication of how many hospital beds could be freed up. The feasibility assessment helps prospective clients to build a business case for Hospital at Home services.

Contents of a feasibility assessment

  • During a pre-visit call we discuss your current situation and concerns with patient flow.
  • We then carry out a desk-based review of relevant documentation.
  • Our experienced clinicians visit your senior management and clinical teams on-site to discuss the current challenges.
  • We ‘walk the ward’ with your teams to identify opportunities to discharge patients and how we can help you.
  • You can ask us in-depth questions about our Hospital at Home service delivery and governance.
  • We collate and summarise findings from this survey and present this back to you within two weeks of the visit. The assessment will include a solution-based proposal with suggested staffing model (HomeLink Healthcare provide our own staff) and outcome-based measures.

The feasibility study forms part of our seven step end-to-end process:


Work with us 

Find out more about HomeLink Healthcare’s Hospital at Home services and the process of commissioning HomeLink Healthcare to set up a hospital at home service. 

Get in touch 

To speak to a member of our team about our services or to book a free feasibility assessment, call us on (020) 3137 5370 or contact us.  

Admission avoidance case studies

HomeLink Healthcare’s Admission Avoidance pathway is helping the NHS to avoid emergency admissions, which in turn improves hospital flow, patient outcomes and saves the NHS money.

The case studies below provide examples of the types of patients we are able to support, along with the wider benefits to patients and the NHS.

NNUH Virtual Ward service helps respiratory patient avoid multiple hospital admissions  

Ron, aged 75, has an extensive medical history including moderately severe bronchiectasis (diagnosed in 1969), emphysema and diverticulosis. Ron has open access to the respiratory team at the Norfolk and Norwich University Hospital due to his condition. He has received care from HomeLink Healthcare on a number of occasions over the last year for recurrent exacerbations of his bronchiectasis.  

On one occasion Ron was referred for thrice daily antibiotics, midline care and weekly blood tests to assess the effectiveness of treatment. He was facing a long stay in hospital at a time when his wife was in the terminal stage of an illness and receiving end of life care. Sadly, during Ron’s 14 days’ treatment, his wife passed away.  

HomeLink Healthcare work collaboratively with the respiratory team in the hospital for bronchiectasis patients and Ron is one of a number of patients who we provide treatment to on a Virtual Ward in their own homes.  

Patient at QEH avoids hospital admission and multiple GP appointments 

Brian, aged 68, has Type 2 diabetes which is controlled by tablets. Brian stood on a stone which penetrated through his footwear and lodged into the ball of his foot. He couldn’t feel pain or discomfort and was unaware of the injury which his wife noticed. The GP referred Brian to the diabetic foot clinic at the Queen Elizabeth Hospital, Kings Lynn (QEH) where an X-ray indicated an infection in the bone.  

Patients who are deemed fit to avoid hospital admission are referred by Consultants and specialist nurses in the Outpatient team to the QEH at Home team (a partnership between the hospital and HomeLink Healthcare). The Consultant referred Brian to us so that we could administer IV antibiotics at home three times a day. During these visits we also provided wound care and blood testing as required. As well as avoiding a hospital admission, the service freed up capacity in his GP practice, where he would otherwise have needed three appointments a week with the GP practice nurse.  

After five days, the Consultant reviewed the results and advised for antibiotics to continue for a further seven days with ongoing wound care and blood tests.  

Brian was very happy to be treated at home as he had experienced two hospital admissions for surgery in the last six months. He remained under QEH at Home care to complete his treatment enabling him to avoid another hospital admission that would have blocked a muchneeded bed for weeks. 

The wider benefits for Admission Avoidance patients 

By treating patients like Ron and Brian at home, we are able to prevent recurrent hospital admissions, improve patient experience and help improve patient flow. 

Bed days saved: On average, HomeLink Healthcare Virtual Wards save 9 hospital bed days per patient. In Ron’s case, this service saved the hospital 14 bed days and in Brian’s it was 12 days.   

Better patient experience and outcomes: Research by the British Geriatrics Society shows that there are similar outcomes for those allocated to hospital at home versus hospital admission for the main outcome of living at home. The research found a reduction in admission to new long-term residential care and high levels of patient satisfaction for hospital at home.  

HomeLink Healthcare’s own clients report a self-reported average 9.3% improvement in all health outcomes. 98% of HomeLink Healthcare’s patients would highly recommend our services to their friends and family. 

Work with us 

Find out more about HomeLink Healthcare’s Hospital at Home services and the process of commissioning HomeLink Healthcare to set up a hospital at home service. 

Get in touch 

To speak to a member of our team about our services or to book a FREE feasibility study, call us on (020) 3137 5370 or contact us.  

In-reach physiotherapy service in care homes benefits patients and hospitals

At a system level an in-reach re-ablement service is a safer and lower cost option for the ICB than providing 24/7 care and physiotherapy in the patient’s home.

In order to free up hospital beds and improve patient outcomes, Norfolk and Waveney Integrated Care Board (ICB) spot-purchase beds in care homes for patients who need up to four weeks’ re-ablement.

HomeLink Healthcare has been working in partnership with hospitals across Norfolk and Waveney since 2019 to provide Hospital at Home services. In February 2023 the ICB commissioned HomeLink Healthcare to provide an in-reach re-ablement service in care homes.

The in-reach reablement service means that patients from James Paget University NHS Hospital Trust can be discharged when they are deemed medically fit and would benefit from ongoing reablement before they are able to return home.

Virtual WardPatients are assessed by a HomeLink Healthcare physiotherapist in the care home within 72 hours of admission and start receiving physiotherapy and re-ablement immediately. The physiotherapist designs an individualised re-ablement programme, which is delivered by re-ablement support workers, and reviewed as needed by the physiotherapist. The team engage with and encourage care home staff to support patients with their exercises between visits.

The HomeLink Healthcare team attend the weekly multidisciplinary meetings to facilitate discharges and refer onto other community services including social services and community physiotherapy, ensuring patients ongoing care needs are met when they return home.

Patients returning home after receiving re-ablement services in a care home are typically more independent when they return home. As a result they need less ongoing support and smaller ongoing packages of care that than they would have needed without the service 

On average patients in the Norfolk in-reach re-ablement service have seen 11% improvement in their mBarthel score and a 19% improvement in mobility in their self-reported EQ-5D-5L score.

At a system level, an in-reach reablement service is a safer and lowercost option for the ICB than providing 24/7 care and physiotherapy in each patient’s home. 

Patient stories 


Sam is a long-term smoker who lives alone in a second-floor flat. He had an acute kidney infection followed by COVID-19 as an in-patient. This resulted in him needing thrice-weekly kidney dialysis due to kidney disease. Prior to hospital admission Sam was fully mobile and independent in all activities of daily living.

Sam was discharged from hospital to a care home for re-ablement. Sam presented with shortness of breath on exertion which limited his ability to walk any distance and to climb stairs. He was also anxious about getting short of breath and lacked confidence about climbing stairs alone after a long hospital stay.

When Sam became medically fit for discharge, there were concerns around his ability to manage at home independently and Sam was therefore transferred to a care home to receive ongoing support. In the care home a HomeLink Healthcare physiotherapist assessed Sam within 24 hours of arrival and provided Sam with a series of stamina and muscle strengthening exercises. In between Sam’s therapy visits a HomeLink Healthcare re-ablement support worker carried out sessions to increase Sam’s confidence and also involved stair practise. This enabled him to improve his stamina and confidence following his illness which had led to Sam feeling deconditioned.

Sam was very pleased with his progress as he reported feeling stronger in general. Following completion of his re-ablement package he was able to manage the two flights of stairs required to be able to return home to his flat. The HomeLink Healthcare team ensured that a package of care was arranged to help with shopping.


Glen had bilateral fractures of his pubic rami. This resulted in an enforced period of bedrest. He was unable to weight-bear and required a hoist to transfer. Glen’s past medical history included diabetes and long-term leg ulcers due to peripheral vascular disease and neuropathy.

Prior to his hospital admission Glen had been independently mobile with a frame and had been independent in all activities of daily living.  He lived with his partner, but in order to return to their new property, Glen needed to be independent with his bed mobility to support his toileting needs at night and his functional independence.

Glen was discharged from hospital into a care home for short-term re-ablement. When a HomeLink Healthcare physiotherapists assessed Glen in the care home he was starting to transfer a few steps with his frame with some support. Pain, along with the poor skin condition of his legs and toes, was however impacting on his rehabilitation.  The pain was addressed and the physiotherapist provided a course of strengthening exercises as well as bed mobility and functional activities such as accessing the bathroom and completing toilet transfers.

The physiotherapists along with a HomeLink Healthcare re-ablement support worker also worked on Glens balance within the limitations of toe pain and building stamina and confidence with his frame. Following the completion of his re-ablement package Glen became independently mobile with the frame and with bed transfers and toileting.

Glen said that he felt the service had improved his strength and confidence. He also felt positive that he and his partner could manage on his return home.

Through attendance at the weekly multi-disciplinary meeting HomeLink Healthcare facilitated an Occupational Therapy Assessment, issue of equipment, and the provision of a package of care for personal care only. Glen was then able to return home safely.

About HomeLink Healthcare 

HomeLink Healthcare is a clinician-led, specialist Hospital at Home service provider.  We have been delivering safe, high-quality services to NHS patients in the place they call home since 2016. 

HomeLink Healthcare have successfully delivered this service in care homes in Norfolk and South East London and would we are able to replicate this service in other commissioned services where we provide a physiotherapy-led service. 

Work with us 

Find out more about HomeLink Healthcare’s Hospital at Home services and the process of commissioning HomeLink Healthcare to set up a hospital at home service. 

Get in touch 

To speak to a member of our team about our services or to book a FREE feasibility study, call us on (020) 3137 5370 or contact us.  

Physiotherapy at Home reduces care costs by over 65%

In Fred’s case this intensive physiotherapy resulted in a happier patient, roughly a 65% reduction in care and a saving in care costs of over £1,000 per month.

Fred (not his real name), who is in his 80s, lives at home with his wife. In recent years he has had multiple health problems and in September 2021 had a bad fall and was admitted to hospital. Fred’s son, says that his father then contracted Covid several times. At one point the family were called to the hospital as doctors thought Fred was near the end of his life. When, in April 2022, Fred was discharged home his Barthel score was 15, indicating total dependency. Care was provided by a domiciliary care agency and he needed two carers, three times a day, seven days a week. In May, Lewisham Adult Therapy Team (LATT) referred Fred to HomeLink Healthcare to provide physiotherapy support 

Shirley Forson, HomeLink Healthcare’s Clinical and Operations Lead for Therapies, says: 

“We first supported Fred from May to mid-June and were commissioned to provide six double-handed physiotherapy sessions. The goal was to improve his sitting balance and to enable him to use a Sara Steady with the assistance of a single carer, as he was previously mobile with a Zimmer frame. At the end of six sessions he was discharged having made a small gain, but given the limited number of sessions he didn’t progress as much as he could have done.” 

"The more independent dad can get the better. Originally, he had two carers three times per day. Now one carer comes three times a day Monday to Friday and we don’t have anyone at the weekends."
- Fred’s son

Fred was then readmitted to hospital in June with an unrelated health condition. When, after 10 days, he was discharged and referred back to HomeLink Healthcare. His mobility had deteriorated and he was “totally bed bound”.  

Shirley says:  

“We completed another six double-handed sessions, lasting until mid-July, with the same goals as the first time. Again, progress was limited.” 

Fred was then hospitalised once more and when discharged in August, was referred back to HomeLink Healthcare for a third time. We then supported him for a longer period, discharging him on November 4th after 28 sessions. This time, there was real progress.  

Shirley reports that during this third referral:  

“Fred went from being bedbound, needing double handed support and assistance with everything, to using a walking frame on his own with just someone around to give him reassurance. He can get to the commode by himself and can now get to sitting on the bed on his own, whereas previously he needed two people to help. He can also transfer on and off the stairlift with one person’s assistance, so can once again access both levels of his house.”  

Fred’s Barthel score went from 15 to 74, indicating a massive change to quality of life and independence. Furthermore, his mood has improved and he feels better about his health. HomeLink Healthcare uses the EQ-5D-5L self-assessment, health related, quality of life questionnaire. This measures quality of life over five categories: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each category is rated out of 5, with a score of 5 indicating very poor  and a score of 1 being very good. Fred’s scores improved significantly across all 5 domains as shown in figure 1 below.  

Fred's EQ5D5L score Figure 1: Fred’s EQ-5D-5L score

Shirley says: 

“EQ-5D-5L also has an overall health rating, which asks ‘How good or bad do you feel about your health’ (0 = 0 terrible, 100 fantastic). Fred started at 30 and ended up at 100.”  

This is an atypical case. Shirley says that in the LATT service therapists usually only see patients three times due to staff availability and referrals to HomeLink Healthcare are typically limited to six sessions. It demonstrates, though, that a greater investment in therapy earlier on can improve patient outcomes and reduce costs in the longer term. 

Alex Negurita Community PhysiotherapistAlex Negurita, Community Physiotherapist for HomeLink Healthcare says: 

“Fred made huge improvements between his physiotherapy sessions. It helped that he was so motivated and he really engaged with the exercises in and between sessions. I was impressed with what he was able to achieve, and I am pleased to have been able to help him to become more independent. I wish him and his family the best of luck for the future.” 

Small steps and big changes

Progress was easy to see, as each time Pat could do more than the previous visit, which was only a few days earlier. By the final session she was able to walk to her front door and back, without a frame.

In Autumn 2022 Lewisham Adult Therapy Team (LATT) referred Pat (not her real name), aged 65 to HomeLink Healthcare for six 45-minute sessions of physiotherapy, including an initial assessment. She had just been discharged from hospital with Type 2 respiratory failure. Furthermore, she had a complicated medical history including breast cancer, obstructive sleep apnoea, type 2 diabetes, asthma, and a TIA that weakened her left side. When discharged from hospital Pat was bedbound.

Samantha Rusike, a HomeLink Healthcare Physiotherapist, says:

“Pat was in hospital for three and a half weeks, and HomeLink Healthcare saw her after discharge from hospital. Pat was in a downstairs room with a hospital bed, a walking frame, a commode, a wheelchair and a new sleep apnoea machine. She could get up and sit on the edge of the bed and stand up onto the walking frame at this point her daughter was doing strip washes for her mother in bed. Pat wanted to walk independently and get to the downstairs bathroom.”

During the initial assessment session Pat could walk with her frame for about two metres if somebody followed her with a wheelchair. She would then become very tired and would need to rest and use her inhaler before moving again. The HomeLink Healthcare Physiotherapist, Samantha, worked with Pat, and together a co-produced physiotherapy programme was developed to build up Pat’s exercise tolerance. As well as practising in the sessions, Pat was given exercises to do in her own time. Pat’s daughter was encouraged to attend most of the sessions and supported her mother to do the exercises in between sessions.

In many physiotherapy services, a patient is seen once and given some exercises, and then not seen again for sometimes up to a month. The impact of the physiotherapy depends a lot on whether the patient can maintain the exercise plan. In this case, twice weekly visits helped establish a rapport between Pat, her daughter and Samantha. At each session Samantha encouraged Pat to walk further and do more exercises. Progress was easy to see, as each time Pat could do more than the previous visit, which was only a few days earlier. By the final session she was able to walk to her front door and back, without a frame. She was also showering, with her daughter’s support.

Samantha says: “When patients have one session a month and then don’t do much, it’s hard to monitor and see the progress. When they are seen twice a week it is easy to see if someone hasn’t done their exercises or if they are struggling and need their programme modified.”

As part of the initial referral, HomeLink Healthcare was asked to assess what extra equipment Pat needed. For example, she wanted a bed lever so she could pull herself up. But by the end of the sessions she didn’t need this or any extra equipment. She was more confident moving about the house and more independent with washing.

Pat says:

“When Samantha came she helped me walk much further than I had walked in 4-5 years. My daughter is trying to carry on Samantha’s great work. Some days I am really tired, but my daughter and my two-year old granddaughter egg me on to do the exercises. Having encouragement makes you want to do things. I’m much better at walking now – I can do lots of things myself. I can get up from the bed by myself (no help needed) and I can use the commode on my own (in hospital I had to use a bed pan).”

Pat’s daughter adds:

“Samantha was really encouraging and patient with mum. When mum reached a small goal, she added something else. The small encouragement meant a lot.”

These changes in Pat’s life might seem like small steps, but they have had a big impact on her independence and wellbeing. Pat reflects “I nearly died when I was in hospital and I am so grateful to everyone at the NHS and HomeLink who helped me to get to where I am today. That’s why I want everyone to see my story and how the NHS and HomeLink Healthcare helped me” she says.

Within a few weeks Pat got to the stage where she could be discharged from the community physiotherapy team’s list. The impact on patient flow would be significant if that outcome were multiplied across many more people.

Samantha concludes:

“We have very few patients coming back for a 2nd time because of the level of initial input we can give. HomeLink Healthcare can help with these patients over five or six sessions, so that they don’t have to come back again.”

Case study: Partnership with Buckinghamshire Healthcare NHS Trust

For some time, delays in discharging patients from Amersham Hospital in Buckinghamshire meant the hospital’s in-patient bed base was at capacity, with beds occupied by patients medically fit for discharge. This led to problems with patient flow and reduced availability of ‘step down’ care in the hospitals. It also created a continuous back log of patients for the NHS Trust’s intermediate care teams, thus delaying patients return to home.

Buckinghamshire Health NHS Trust (BHT) commissioned HomeLink Healthcare to provide Early Supported Discharge, Rehabilitation and Bridging Package of Care to support with delayed discharges.

"I’ve worked with a lot of providers and HomeLink Healthcare are a very professional organisation. Every member of my team have said how respectful and courteous your staff are. It has been a pleasure to work with a partner who does exactly what they say they will”
- Jenny Ricketts, Director of Community Transformation

During the initial stages of our discussions in Summer 2022, funding was not yet in place and the type and amount of support the hospital were looking for had not yet been defined.

HomeLink Healthcare carried out a free Point of Prevalence survey, walking the ward and consulting with the ward nursing team to estimate the percentage of patients we could transfer into our care. We discussed and reviewed the potential solutions with BHT and in partnership created a bespoke service that would best impact patient flow and support BHT’s intermediate care teams.

We agreed on an Early Supported Discharge and Rehabilitation pathways, both of which included the option for Bridging Package of Care and made a formal service proposal. Six weeks later we started mobilisation against a fixed price and set of agreed outcomes.

Typically, the mobilisation process for brand new services takes eight to 12 weeks. In this instance it took nine weeks.

HomeLink Healthcare uses PRINCE 2 project management approach, led by a dedicated Project Manager. This focuses on working in partnership to move initiatives through predefined stages across seven workstreams: service and pathway design; clinical governance; information governance; IT; contract and finance; communications; and workforce.

An average of nine hospital bed days saved per patient

An initial kick-off meeting with the full HomeLink Healthcare and BHT team set out the parameters and timescales of the project. This was followed by individual meetings between HomeLink and BHTs workstream leads. Weekly checks were held between the two project leads.

The first patient was referred to us on 1st December 2022 and as with all new services, we went through a four-week, post go-live intensive programme of checks and support. We always start small to ensure the service is delivering as planned in a safe and effective manner. ‘HyperCare’ ensures that the service is delivering to schedule and on track to meet all outcome-based measures.

When the service launched, we aimed to complete 20 visits in the first week and ramp up to full capacity over the following weeks. Over the first six weeks we overperformed, completing 115% of the required visits.

This service saved 951 bed days in the first 18 weeks.

After 18 weeks we had saved 951 bed day, an average of 53 bed days per week. Getting people out of hospital sooner than they would ordinarily have been able to has had a significant improvement on patient flow in both Amersham Hospital and Olympic Lodge (a step down facility).

"The staff have been brilliant, I am going to miss everyone!”
- Patient feedback

Peggy, age 94, was referred to us on 1st December following a fall. We started care on the same day which meant that Peggy could leave hospital four days earlier than she would have been able to had she had to wait for her social care package.




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Find out more about the process of commissioning HomeLink Healthcare to set up a hospital at home service.

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To speak to a member of our team about our services, call us on (020) 3137 5370 or contact us. You can tell us about your situation, and we can tell you more about our experience of supporting our NHS partners and how we might be able to help you. 

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