Care Transfer Hub helps people return home from hospital

A dedicated Care Transfer Hub is playing a vital role in ensuring that patients in Shropshire, Telford, and Wrekin who no longer need hospital care can return home as soon as they are medically ready.

Since its launch in October 2024, the hub has helped to significantly reduce the number of patients waiting in hospital beds for discharge into home or community care settings. It’s also shortened the average wait times for discharge and advocates a “home first” philosophy, supporting patients returning home from hospital.

The hub brings together staff from the NHS, Shropshire Council, Telford & Wrekin Council, and the voluntary and community sector. Together, these multi-organisational professionals facilitate safe and timely discharges, ensuring appropriate support is in place for each patient.

By enabling these multidisciplinary teams to coordinate discharge planning effectively, the hub identifies the best and safest options for patients who are medically fit to leave hospital. This collaborative effort involves social care, housing and voluntary organisations working in partnership to ensure patients receive the timely support they need.

Sarah Robinson, Clinical Divisional Manager Urgent and Emergency Care for Shropshire Community Health NHS Trust, explained: "Discharging patients as soon as they are fit to go home has a significant impact on their recovery and overall health outcomes. Being in a familiar environment, surrounded by home comforts and loved ones, is essential for physical and emotional well-being.

“Reducing delays is particularly important during winter, a time of increased illness and demand for hospital services.

"People often recover better at home, and it’s our responsibility to support them in returning to their communities as quickly as possible. Working with our partners across health and social care, we’re ensuring patients have the care they need to continue their recovery safely.

"By collaborating with health, social care, and community partners, we’re helping more people to return home from hospital safely and continue living well in their own homes."

Jo Williams, Senior Responsible Officer for Urgent and Emergency Care for Shropshire, Telford and Wrekin and Chief Executive of the Shrewsbury and Telford Hospital NHS Trust, also expressed strong support for the hub’s work and its potential for further expansion: "The dedication and collaboration of everyone involved in the Care Transfer Hub is making a real difference to people’s lives, ensuring they receive the right care, in the right place, at the right time.

"I want to personally thank all those working tirelessly to support timely hospital discharges and patient recovery. Your efforts are not only improving outcomes for individuals but also

strengthening our entire health and care system. We are committed to building on this success and expanding the hub’s impact even further.

“By coming together as one team across our partnership, we can tackle the biggest challenges and make a real difference. We are ‘Stronger Together.’"