The programme is made up of 5 independent projects. 4 service integration projects that promote independence and active recovery at home (short-term community rehabilitation and reablement, both for step-up and step-down care), enhanced care at home, community rehabilitation and recovery beds and transfers of care. It relies on strong working relationships across all system partners, including third-sector organisations. A fifth project focused on system visibility and active leadership was established to enable this.

Key learnings

A key building block for developing these relationships and team approach was the creation of a system-wide reporting suite and access to a common analytics dashboard, which all partners trust to provide a single truth of system flow.

• These tools empower leadership and improvement groups to understand the biggest blocks to capacity and outcomes and where to direct their support.
• The programme invested in short-term resource, both financial investment and in-kind alignment of colleagues from the Leeds system, to support design, build and testing of the dashboard.
• The initial scope was refined for feasibility to largely focus on acute hospital discharge pathways in the first instance. Work is ongoing to develop a mental health equivalent and a home-focused (admission avoidance) zone.
• Leeds HomeFirst is embedding a culture of data-driven decision-making with the visibility to see how people are moving through the health and care system, working together to help more people return or stay at home.

Impact

As of November 2024, the programme reported the following impact against its key performance indicators (6-month average, against baseline):

• 869 fewer adults admitted to hospital each year
• 571 additional people benefitting from reablement each year
• 435 more people going directly home each year after their stay in hospital, instead of a bedded setting
• 131 more people able to go home after their time in intermediate care per year, instead of moving to long-term bedded care
• 28% reduction in hospital no reason to reside length of stay for people needing support post discharge
• 7.1 day reduction in average length of stay in rehabilitation and recovery beds

As of November 2024, the programme impact is reported to translate to £24.3 million per annum of financial benefit to the system, provided the current performance is maintained. These benefits are spread across system partners and combine cost out, future cost avoidance and investment in quality.

Leeds HomeFirst is monitoring the experience of people and their carers through patient reported experience measures in community beds and reablement services. As of November 2024, these indicate positive movement in all indicators, particularly involvement (increased from 55% to 82%) and communication (increased from 73% to 90%). There is also a dedicated transfer of care survey supported by hospital volunteers. Staff experience is being tracked across the programme.

Publication reference: PRN01756_ii