In this section...

  1. How we make decisions
  2. Our priorities
  3. Policies and procedures
  4. What we spend and how we spend it
  5. Who we are and what we do
  6. Work for us
Nurse with patient on the virtual ward

Make it easier to treat people at home than to admit them to hospital

We know more and more people want to be treated in their own homes. For many people, especially those with long-term conditions and frailty, we know outcomes can be better this way. With the way that care is currently designed, the demand for hospital-based care is more than the beds and resource we have available in mental and physical health. An ageing population will need more care and treatment. If we can support people, treat them sooner and work together with our partners in primary and social care we can prevent relapses and avoid crisis and keep people safe and well cared for at home.

This needs to get easier. We will need to work with patients and carers to make this happen in a way that makes people feel safe and gives them the best care. We will need great technology and wide cooperation across the teams in our localities to make it possible to treat people properly and effectively, whenever appropriate in their own homes.

How we will do this

Work with our partners to deliver a shared approach to admission avoidance

We will build on the progress made in recent years to develop and deliver a shared model for admission avoidance services across our system, including Hospital at Home, urgent treatment centres, same day emergency care (SDEC) and a single point of access (SPOA). This model will initially focus on the frailty cohort but will over time expand to cover all adults who use our community health care services.

Develop alternatives to admission for people needing short-term crisis support in mental health

We will develop high fidelity models of CORE24 liaison psychiatry, home treatment teams, crisis resolution and multi-agency response services for children and young people in mental health services, reaching into VCSE provided alternatives to admission.

Innovate in our use of data and information technology

We will promote patient engagement with innovative new technologies to monitor their long-term conditions and enable early intervention to prevent relapse, to allow for early discharge and to manage illness at home when it does occur.

How will we know we have achieved this?

We will know we have achieved this when:

  • each integrated neighbourhood team will have a stratification of our population to understand who is at risk of relapse and admission
  • each person has a personalised care plan and access to a personal budget if required
  • we have implemented a shared model of admission avoidance across the county, utilisation of admission avoidance services is high and we can demonstrate the impact on reducing admissions to the acute hospital
  • length of stay will be below the national average on our mental health and community wards
  • fewer people are admitted for short-term mental health crisis support, leaving our inpatient care for those that really need it and reducing out of area placements

Linked Care Quality Commission statements

  • Independence.
  • Choice and control.
  • Care provision.
  • Integration and continuity.