How Oxfordshire's Transfer of Care Hub is helping people home from hospital
18/12/2024
A Transfer of Care hub is ensuring patients who no longer need to be in hospital return back home as soon as they are well.
The hub is made up of staff from Oxford University Hospitals (OUH), Oxfordshire County Council, and community services, who all work together to get people home quickly and safely from hospital, with the right support in place.
Since the hub was set up in January 2023, the number of people in hospital beds waiting to go home or into community care has reduced to less than 90 a day, from a peak of 135 in 2022 – including a recent low of 59.
In addition, the number of people returning directly home from hospital has increased from 90 percent in 2022 to just shy of 93 percent in 2024. The average length of time people wait to leave hospital has also decreased from 10 days in September 2022, to six days in September 2024.
The hub enables our multidisciplinary teams to find the best and quickest discharge options for patients who are medically fit enough to leave the hospital by working with other teams across the NHS, social care, housing and voluntary services in Oxfordshire.
Tamsin Cater, Head of the Transfer of Care Hub at OUH, said: "We know that discharging patients as soon as they are medically fit to go home greatly improves their health outcomes.
"That is why we have been working so hard with our partner organisations to reduce the length of stay for our patients who no longer need to be in hospital, and prevent any delays in them returning home or back into the community. This is especially important as we move through winter when there is increased illness in the community and more demand for hospital beds."
Felicity Taylor Drewe, Chief Operating Officer at OUH, said: "Discharging people as soon as they are fit and well is vital, as prolonged stays in hospital are bad for patients, especially for those who are frail or elderly. More often than not, people want to be around their home comforts when they recover, in familiar surroundings with people they know. Working with our partners we are together addressing people staying longer than they need to support their onward care."
The hub forms part of a system-wide approach to getting people home from hospital safely and quickly, including the Discharge to Assess (D2A) programme.
Sally Steele, Head of Hospitals for Oxfordshire County Council, said: “By working with health and social care partners, as well as organisations from the community and voluntary sector, we are supporting people to head home from hospital quickly and safely.
"Between January and November this year we discharged 4486 people under D2A across the county of Oxfordshire, and we’re supporting even more people to live well, at home, for longer."
People can also help ensure NHS services are available for those who most need them this winter by ensuring they access the right care for their needs. If it's not an emergency, people are asked to contact 111, visit a GP, an Urgent Treatment Centre, or pharmacy.
People can also ensure they are taking care of their own health by having their flu and COVID-19 vaccinations, keeping warm in the winter months and making sure they order all their medications in good time. It's also important for people to look out for vulnerable family members and neighbours during the colder months.