Arrangements for care from hospital to community
Transfer of care network
The transfer of care service is a service provided by Leeds Community Healthcare based within St James University Hospital. There are three teams within the service which include the Community Discharge Assessment team, transfer of care, and bed bureau. Our teams are based within the trust headquarters at St James’ Hospital and operates 7 days a week, 365 days a year (including weekends and bank holidays).
Transfer of care hub
The transfer of care hub is designed to improve people’s care by ensuring that people are discharged from hospital in a safe and timely way, receiving the right care, at the right time in the right place. We are committed to delivering a home first approach and supporting people to return to their usual place of residence wherever possible. We work closely with patients and families referred to our service to input care and provide guidance on available services. The transfer of care service works closely with the hospital, social care, housing and third sector groups to ensure safe and timely discharges from hospital.
We work with the teams in the hospital to identify the pathway and services a person may need when they are ready to leave hospital. We will gather information about the persons needs and arrange for services to support peoples ongoing care needs.
Community Discharge Assessment team
The Community Discharge Assessment team (CDAT) are a team of nurses, occupational therapists and physiotherapists based at St James’ Hospital in both the Emergency department, same day emergency care and four acute wards. The team will liaise with the neighbourhood teams (NT), self-management, adult social care, and voluntary sector to facilitate discharge and prevent hospital admissions.
CDAT provide case management to patients to help avoid unnecessary or avoidable hospital admission, supporting the Home First approach ensuring patients receive the right care, in the right place, at the right time.
Bed bureau
Bed bureau provides the bed management of over 150 community care beds (CCB) across Leeds. Bed bureau support with identifying a community bed for people who no longer need to be in hospital but cannot return directly to their own home. The focus for these patients within a CCB is recuperation, rehabilitation and recovery. This also includes patients being discharged for assessments (D2A). Bed bureau also work to avoid unnecessary hospital admissions by liaising with community services.
