Brian, a user of our intermediate care services, says, “At the end of the day, you can’t beat your own bed.” We agree. People have better health outcomes and care experiences at home or close to home. In Leeds we have been transforming our intermediate care services with partners from NHS Trusts, local authorities, and other sectors working together. This collaboration has led to over 1,200 fewer hospital admissions annually, a one-third reduction in hospital stays, more people receiving care in better settings, and more.
Like all health and care systems across the country, in Leeds we have been facing a range of challenges in the delivery of intermediate care, driven in part by an aging population with increasingly complex health conditions. Over the past two years, partners in the NHS and social care, have worked together to improve intermediate care in Leeds – this has been known as the HomeFirst programme.
At the core of HomeFirst are innovations that make care more joined-up and person-centred:
- Recovery Plan: A shared digital tool helping professionals and families work together on one care plan.
- Tracker App: Real-time updates from home care staff support quicker, safer discharges.
- Case Management: A new model bringing the right team to the person, reducing delays and improving outcomes.
- Redesigned Roles: Embedding social workers in bed-based services to guide people through their care journey.
- Active Leadership: Using data and structured collaboration to solve problems and improve care.
The changes we have implemented have so far resulted in 1,200 fewer adults getting admitted to hospital, and for those people that have had a hospital admission, the length of their stay has been cut by nearly 40% on average, and more than 400 people went straight home after a hospital stay instead of into an intermediate community care setting. We have also seen an improvement in the experience of people who use our services because of the changes we have made.
These improvements have only been possible because of the HomeFirst Programme, which united health and care partners behind a vision to enable a sustainable, person-centred, home-first model of intermediate care across the Leeds that is joined up and promotes independence. In essence, we set out to ensure that more people can stay at home to receive their care, or return to their home sooner, rather than staying in hospital – but only when it is medically safe for them to do so. By doing this, we know we will help people have a better recovery and improve their health outcomes.
Health and care partners continue to work together to build on the positive outcomes we have already achieved by transforming intermediate care services, with further changes being planned in the next stage of development.
Frequently asked questions
What is intermediate care?
Intermediate care is a collective term for a group of services, designed to provide short-term help for adults, who need continuing support once they have been discharged from hospital, or to avoid being admitted to hospital. They aim to improve recovery and increase independence.
If you work in Leeds health and care, or have been a hospital patient, you may know some of the services as Neighbourhood Teams, SkILs (Skills for Independent Living) Reablement, Rehabilitation and Recovery Beds, and Home Ward (or Virtual Ward).
What is the HomeFirst programme?
The HomeFirst programme consists of five interrelated projects which focus on maximising independence and ensures that people always achieve their best outcome.
The five projects are:
- Active Recovery at Home: redesigning the home-based intermediate care offer to maximise capacity and deliver the best outcomes for people accessing these services.
- Enhanced Care at Home: transforming preventive services to avoid escalations in need with a specific focus on avoidable acute hospital admissions.
- Rehab & Recovery Beds: transforming bed-based intermediate care to improve outcomes and minimise length of stay in short-term beds.
- System Visibility & Active Leadership: making use of the wealth of data in the system to produce system and service level dashboards, while establishing the right cross-partner governance to use these for effective decision-making.
- Transfers of Care: redesigning the discharge model to minimise discharge delays and ensure the system achieves the most independent outcomes for people leaving hospital.
The new ways of working have been designed, trialled, iterated and scaled by experts including frontline staff and leaders from across the system.
What has the HomeFirst Programme achieved?
Our latest data shows the programme has had the following impact:
- 1,256 fewer hospital admissions each year.
- 383 more people supported through reablement services annually.
- 418 additional individuals returning directly home after hospital, avoiding unnecessary care home stays.
- 103 more people transitioning home after intermediate care instead of entering long-term residential care.
- A 38% reduction in hospital stays for those needing post-discharge support.
- An 8.4-day reduction in average stays in rehab and recovery beds.
As well as benefitting local people by improving their health outcomes, these outcomes also provide a financial benefit to the health and care system, enabling us to make better use of our resources.
Which local partners have been involved in HomeFirst?
The HomeFirst programme is a truly collaborative undertaking, which when fully implemented will see staff and teams in intermediate care working better together. The changes are being delivered by Leeds City Council, Leeds Community Healthcare NHS Trust, Primary Care and the GP Confederation, Leeds Teaching Hospitals NHS Trust, Leeds and York Partnership Foundation Trust, and charity and voluntary sector organisations.
I work in intermediate care in Leeds, I want to find out more
We have made significant progress in delivering our change programme, but there is still more to do. We are currently planning for the next phase of delivery (as of October 2024), and if you work in intermediate care services, we will be providing more information about the next phase in due course. In the meantime, you can talk to your line manager, as we are working hard to keep all managers up to date with the latest information.