Supporting the flow of patient care from hospital to home

Case study Virtual ward, Patient experiences, Partnerships 14th Jun 2019

81% of all patients are being discharged on or before their expected discharge date.

HomeLink Healthcare has been providing clinical care in the home with Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUHT) since January 2019, to release in-patient bed capacity and improve patient choice. The two organisations have co-created the service, NNUH at Home, creating additional capacity and promoting improvements in patient flow from hospital to home. A key feature of NNUH at Home is that it compliments and integrates with existing services, rather than replicating those already in place.

During this time nearly 1,700 bed days have been saved – over 50 beds per week – and has also resulted in outstanding patient satisfaction with 100% of patients saying they would recommend NNUH at Home to their friends and family.

The situation

Delayed transfers of care (DTOC) are a problem for the NHS, and July 2019 saw 139,900 across England – 4,513 people delayed every day. Patients awaiting further non-acute NHS care were one of the biggest reasons for these delays, accounting for 25,100 delayed days (29.6% of all NHS delays).

DTOC can cause considerable distress and unnecessarily long stays in hospital for patients, not to mention the increased risk of infection, low mood and reduced motivation, ultimately affecting their recovery and chances of hospital readmission. DTOC patients also contribute to increased bed occupancy rates, this is in addition to those patients who may not be medically fit for discharge but could continue their sub-acute care at home.

In England, from April to June 2019, overnight beds were measured at an average occupancy rate of 90%, which is not in line with suggested maximum safe bed occupancy levels, currently set at 85%, therefore more needs to be done to address this problem.

Delayed transfers and high bed occupancy rates have a wider impact on the health system, causing delays in A&E and elective care cancellations, as a reduced number of beds will be available for other patients. Early supported discharge (ESD) and virtual wards can help address these problems by assisting the flow of patients from hospital to another setting for continuation of care and treatment.

Finding the solution

NNUH at Home contributed to the trust reducing delayed bed days by 18% (2019 vs 2018).

 NNUHT is committed to reducing DTOC and the need for escalation beds, promoting effective and efficient patient flow, minimising delays and maximising utilisation of hospital beds. Several programmes of work have been initiated to bring financial and operational efficiencies into the trust.

Analysis of hospital data during winter pressures planning in summer 2018 indicated there were opportunities at NNUHT to improve patient flow and relieve pressure on beds.

In a bid to realise efficiencies, in September 2018 NNUHT established a partnership with HomeLink Healthcare, a CQC registered company experienced in home-based clinical care, to deliver and evaluate ESD and virtual ward services. This became NNUH at Home.

NNUH at Home service initially focused on two patient pathways:

+ Early supported discharge (ESD), which provides bridging packages of care, so patients who are medically fit can be discharged from hospital. The NNUH at Home team provides care until longer term community services are available.

+ The virtual ward, which provides clinical care at home for patients who are medically stable and can finish treatment at home, while remaining under the care of the hospital consultant. For example, Intravenous Therapy, Blood Monitoring, Physiotherapy, Rehabilitation or Wound Care.

Developing NNUH at Home together

“I am very appreciative of the care, support and advice I received by experienced staff, which in turn gave me confidence to deal with my health issues. Having support in the community did not feel at all obtrusive”. NNUH at Home patient.

Collaboration was key for successful implementation of NNUH at Home. Teams across the trust, HomeLink Healthcare, community services and commissioners worked alongside one another to agree the service design prior to service delivery. Overseen by the NNUH at Home project board, the governance and safety protocols, referral, escalation and discharge processes, were jointly agreed during the 12-week service mobilisation phase.

Working cohesively with NNUHT’s current process was fundamental to avoid any unnecessary duplication of services, safe, effective and efficient utilisation of the capacity provided by the NNUH at Home pathways.

The NNUH at Home clinicians became part of the trust team, fully embedding by attending multidisciplinary team and bed meetings.

A service designed with patients in mind

NNUH at Home patients are given the choice to spend less time in hospital and receive care at home. They are safe in the knowledge that if there are complications while at home, there is a nurse on the end of a phone 24 hours a day, available to triage clinical concerns.

Patients appreciate the support NNUH at Home provides, valuing its punctuality, efficiency and knowledgeable and caring staff. Family members are grateful for having their loved ones at home, not to mention the amount of time and money saved on countless journeys to hospital.

These sentiments were echoed in the Family and Friends test with 100% of patients stating they would definitely recommend the service to others.

NNUH at Home pathway

Easing pressure at NNUHT

NHS England data shows that over the six-month period from January to June 2019 since HomeLink Healthcare went live at NNUHT there was an 18% reduction in delayed bed days compared to 2018.

Jon Green, Director of Transformation at NNUHT, said: “Thank you to the team at HomeLink who have supported us through the implementation phase of NNUH at Home, providing us with expert advice so the service has seamlessly integrated with the trust. Collaborating with clinical, operational and community teams was essential to the success of the programme and HomeLink were fundamental in enabling this to happen.

It is our mission at NNUHT to support care closer to home, improve patient experience and encourage the best recovery possible, following a period of ill health. We envisage continuing this fantastic work allowing even more patients to recover in the comfort of their own home, safe in the knowledge that they are receiving care of the highest quality.”

In order to continually deliver service improvements and implement learnings, HLHC gathers data from their systems at NNUHT and evaluates this against key performance indicators to measure the effectiveness of the service.

Proving the success

Initial results show NNUH at Home provides safe, efficient and cost-effective capacity, as well as an excellent patient experience. Strong cross organisation working relationships, the skill-mix of the community-based and an on-site team were instrumental in achieving these results. NNUHT has since committed to further working with HomeLink Healthcare, following the success of this programme.



Work with us

Find out more about 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 Hospital at Home 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.


“You did everything exceptionally and allowed me to leave hospital six weeks earlier than planned because of the service you provided.


Patient feedback

“I am so grateful to have been referred to HomeLink Healthcare, they have really helped me get back on my feet. If I had stayed in the hospital I would not have achieved everything I have done”

Patient feedback

“I want to thank you from the bottom of my heart, and let you know that the work you do makes a true difference to people’s lives and wellbeing.”

Dr Vassiliki Bravis Consultant, Imperial College London

“Exceptional, amazing service with highly qualified staff. I felt confident at all times that staff knew how to deal with my picc line and my four times-a-day antibiotics was made easier by such lovely caring and compassionate staff”

Patient feedback

“The visiting therapist took her time with me, was always providing encouragement and without that I wouldn’t be at the point I am today.”

Patient feedback

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