HomeFirst – transforming intermediate care

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.  

We have 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.  

We are pleased to say that the changes we continue to make are already making a big difference. Within the first 18 months of delivering the changes, we saw 1,200 fewer adults getting admitted to hospital, with them receiving the care they needed at home, or in a community care setting. For those people admitted to hospital, the length of their stay has been cut by 17% 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. 

The impact of our work also has positive impacts on the wider health and care system, particularly reducing demand for busy services, and helping make better use of our resources. Our work has been recognised by national, and some international, partners as best practice, and whilst we have already made demonstrable improvements for local people, we know we have more to do.  

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? 

Based on September 2024’s performance, the programme is having the following impact on outcomes across intermediate care in Leeds: 

• 169 more people able to go home after their time in intermediate care rather than a long-term bedded setting each year 

• 8.2 day reduction in the average length of stay in short-term beds  

• 421 more people going directly home after their stay in hospital each year 

• 786 fewer adults admitted to hospital each year  

• 31% reduction in length of stay for complex patients with no current reason to reside  

• 522 additional people benefitting from reablement each year  

• The effectiveness of the home-based reablement offer has increased by 8% (in terms of long-term home care hours following the service), with a 19% increase in the proportion of people leaving the service fully independent 

• 33% decrease in readmission rates after receiving home-based reablement  

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.