HELPING PEOPLE IN COVENTRY STAY INDEPENDENT AND AVOID HOSPITAL: ONE YEAR OF LOCAL INTEGRATED TEAMS

Why change was needed

In 2022, health and social care organisations across Coventry came together to transform out-of-hospital urgent care. A diagnostic review was undertaken that showed that Coventry was an outlier in relation to hospital admissions, length of stay and dependence on long term social care support following discharge. This meant that older people in Coventry with urgent health and care needs were often receiving the wrong support. 

There was a clear need for a more coordinated, personalised approach to urgent and emergency care that would help people recover in the community and regain their independence.

The Improving Lives programme was formed, bringing together community, acute hospital and social care services with local providers to develop the One Coventry Integrated Team (OCIT).

What we did

The organisations committed to an at scale transformation programme of the out-of-hospital urgent health and care pathway.  The OCIT model, which spans admission avoidance in the community, hospital admission, discharge support and reablement was trialled extensively in one area of the city prior to being scaled up across the city. 

In June 2024 Three Local Integrated Teams (LITs) were set up. Each team brings together NHS and social care staff from University Hospitals Coventry and Warwickshire (UHCW) NHS Trust and Coventry City Council, working together as one service to support the whole urgent and emergency care pathway around one shared caseload.  

To support the integration, a shared digital record, designed by staff, was created.

Since launching, the LITs – based at Newfield House, Opal Centre, and Tile Hill Primary Care Centre – have supported over 6,000 people.

Key outcomes over the first year include:

• 840 people avoided an unnecessary hospital admission.
• Over 2,000 people were supported to recover at home or close to home.
• An 86% drop in people needing long-term care home placements.
• 1,420 patients received therapy in or near their home.

One of those helped is 88-year-old Joan Foster from Holbrooks. After a fall at home left her in hospital for eight weeks, her local LIT supported her with home-based physiotherapy, equipment, and care. Within two months, Joan’s care needs had reduced to just one carer visit per day.

Joan said:

“Without the support, I don’t know where I’d be. They gave me the confidence to realise I can do things. I can now get into bed on my own and get to the kitchen to make a cup of tea.”

What’s next?

The success of the LIT model has shown that integrated working across health and social care makes a real difference to people’s lives. The focus for the future is on continuing to scale up the service, share learning and strengthen community partnerships so that even more people in Coventry can benefit.

Jodie Storrow, Lead for One Coventry Integrated Team, said:

“What we have achieved in a year is truly astonishing. I am incredibly proud of the dedication shown by every team member. Together, we are changing how we support people with urgent needs – helping them stay well, stay independent and stay home.”