Developing a therapy-led transitional unit to help discharge acute patients


A case study of a therapy-led unit in South Warwickshire NHS Foundation Trust aiding patients' transition from hospital to home-based care.

What was the aim?

South Warwickshire NHS Foundation Trust found many medically fit patients were occupying acute beds because they were unable to manage at home, and were not yet safe to receive care or therapy there. Typically, they needed support at night or between care calls but no longer required 24-hour nursing.

The trust therefore wanted to:

  • increase patients' independence and daily living skills, avoiding the loss of confidence or ability associated with spending too long in hospital
  • reduce hospital delays and costly long-term health and social care, supporting people safely with less intervention
  • ensure people recover away from the acute hospital to accurately assess their health and social care needs
  • help patients return home if possible, for as long as possible
  • ensure decisions about long-term support are made outside hospital and people have access to therapeutic and reablement services

What was the solution?

The trust contracted with Warwickshire Care Services (WCS) to create a therapy-led transitional unit in Castle Brook, a modern and technologically advanced care home.

Team makeup

The 13-bed unit's NHS therapy team consists of the therapy lead, who is an occupational therapist (OT), a rotational physiotherapist, a rotational OT, a part-time physiotherapy assistant, and part-time OT assistant. The unit has also recruited a Band 4 therapy assistant practitioner.

WCS's team consists of a lead enabler and enablers with extra reablement training to continue rehabilitation while therapists are not on site.

Daily handovers between the trust and WCS allow for effective communication and enhance team integration. A social worker and Age UK representative attend a weekly multidisciplinary team meeting. Three times a week, GPs visit patients who have been identified by the therapy team; district nurses visit as and when required.

Admission and assessment

Technology plays a major part in the speed of admission. The therapy lead screens the patient in the acute hospital, explains the service and gains written consent: it is important the patient understands the transfer is part of their ongoing treatment, and they remain the trust's responsibility.

A trusted assessment is then completed online with baseline information and care plans created for the patient. This is forwarded electronically to the unit for joint agreement that the patient is suitable. This prevents delay that would arise from the home visiting the patient on the ward.


As the unit is based in a care home, it is less institutionalised and more therapy-enriched. Patients receive one-to-one and group therapy and are encouraged to recreate a routine like their own at home.

The criteria require that patients are motivated and engaged with therapy and can return home within 21 days. Castle Brook is a short-stay, low-level rehabilitation unit that focuses on planning for safe discharge and reducing the amount of care or support required on discharge and in future.

What were the challenges?

Bed pressures in the hospital resulted in a room previously used for therapy being filled. Bed pressures also resulted in a need to adjust the criteria to help patient flow, which now allow one patient needing two people's help to mobilise to be in the unit at any one time.

Castle Book also now accepts patients awaiting support from community teams or social services.

Differences between the trust's and WCS's policies and procedures required negotiation and problem-solving from both parties.

What were the results?

  • 1,870 hospital bed stays saved between April and October 2017.
  • Average length of stay for the year to date is 14.3 days.
  • 89% of patients are discharged to their usual place of residence; 9% are re-admitted to hospital and 2% discharged to a care home.
  • 83% return home self-medicating.
  • 96% reduction in patients with night needs on discharge.
  • 100% of patients likely to recommend the service to family and friends (September 2017).
  • 100% of patients improving in at least one aspect of the Therapy Outcome Measure.
  • 93% of patients have improved in the Elderly Mobility Score.
  • The vast majority of patients are discharged with a reduction in predicted care packages on transferring to Castle Brook.
  • Some patients have returned home independently without care support on discharge.

What were the learning points?

  • Allied health professionals are essential for a positive impact on patient flow.
  • Integrated multidisciplinary teamworking is essential.
  • Therapy-led services allow for all patient contact to have therapeutic benefit.
  • Providing rehabilitation in a more homely environment has a positive impact.
  • Partnership with care home staff is essential and allows for more holistic assessment and intervention.

Next steps

There are plans to use the trusted assessment and technology in the home for an enhanced 24-hour rehabilitation service: trust staff would complete daily carer handovers on the system to discuss goals and plan therapy sessions.

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