The Bradford Out-of-Hospital Programme aims to transform the care and support for people with complex care needs, enabling them to be ‘happy, healthy and at home’ for as long as possible. The term ‘Out of Hospital’ simply refers to services that are delivered in community settings to give person-centred care and support that promotes and enables independence. Out-of-Hospital care involves supporting people, understanding and meeting their health and care needs in a joined-up way, covering all areas, so they can live fulfilling lives in their own communities.
- We need to identify new and more sustainable ways of delivering services to meet local health and care needs, ideally close to home.
- Currently care is delivered by a range of organisations in different ways that aren’t always joined-up, which means that people don’t always get the most appropriate care for their needs.
- Currently we tend to use community hospitals for step-down care from acute hospitals, before people return home, but they could have a greater role, for example in community-led admissions; this could also prevent unnecessary acute admissions.
- We need to ensure that how and where people access services reflects the needs and diversity of our communities across Bradford – developing ‘locality based’ services.
- We already provide good services for people who have had a ‘health crisis’ but we need to develop a more proactive and preventative service to avoid health, care or support crises where possible.
- Sometimes, opportunities to prevent a hospital admission are being missed but with the right approach to Out-of-Hospital care, more people could be cared for in the community.
- More community-based diagnostic services would help to do just that – diagnose and treat people close to home.
- Further develop the role of community hospitals to provide more intensive short-term support close to home.
- Develop ‘virtual wards’ that can either support people to leave hospital sooner and/or care for people that become acutely unwell but don’t need acute hospital care, so people are cared for closer to home.
- Pilot multidisciplinary team meetings that bring together a range of professions to support integrated care planning for those people with complex needs, who are identified as being high risk for hospital admissions that could be avoided.
- Provide a single access point for intermediate services that help people recover and regain their independence, with a clear referral route from primary care that usually starts in general practice.
- Develop an integrated health and social care hub to help people access beds across virtual wards, community hospitals and/or social care.
- Use the district’s existing combined therapy and reablement service to support more effective joint working across health and social care.
What does this mean for you?
This new approach will be different because it will enable nurses, social workers, GPs, therapists and third sector organisations to work more closely together with individuals and their carers, to agree a care and support plan that is right for each person. When people do need to go into hospital, they will have an agreed care plan that helps them regain their independence as soon as possible, with intermediate care support provided in the community. It is widely recognised that people can lose skills if they stay in hospital longer than is absolutely necessary. Intermediate care provides extra support to help people either avoid a hospital admission or leave hospital when they might still need extra help, before regaining the independence that they had before. When care and support is needed, it will be ‘the right care, in the right place, at the right time’, ideally close to home.
Why will this help?
By caring for more people in a community setting and reducing duplication across different services, Out-of-Hospital care will lead to better experiences for people and enable us to deliver services more cost effectively and efficiently. Greater use of existing community resources, for example exercise clubs or befriending groups, will also help people to maintain links with their local area, promoting self-care skills and reducing loneliness and isolation. The new ways of working are being developed and delivered by existing providers of health, care and voluntary services across the Bradford district, working more closely together.