Digital Transfer of Care Hubs

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Using a single system to effectively triage, prioritize and process NHS e-RS referrals (and all other referrals in the system) is a game-changer for improving referral accuracy, reducing system inefficiencies, and effectively managing wait times on a prioritized basis for a large-scale referral population.

Referrals that will be better serviced in the community can be streamed to best-match services represented by a complete localized Directory of Services (DOS). ALL available services are known and considered when planning care transitions and assigning packages of care and intervention (rather than just the top 10 services known top of mind to the transition team/referrers).

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Example Scenario

Rose, a 78-year-old living independently at home has just had a fall. It’s Friday 4:30 pm, and her GP practice has just closed. Urgent care stipulates the only safe response is an ambulance to collect and take Rose to hospital. Rose is admitted and her hospital stay becomes >2 weeks, as she catches an infection. Meanwhile, the weekly homecare visits continued while she was in the hospital. The care provider has raised the question as to the fact that Rose is not at home, but this inquiry goes nowhere. The homecare provider continues to get paid while Rose is in the hospital.

In another place-based area, Gerome has a similar fall. The GP OOH has access to the Triage Hub and sends an urgent referral that needs an answer within 30 min. The clock starts, and the team assesses that in the first instance a district nurse should assess Gerome ASAP. The referrals are forwarded on to the team with an urgent escalation to which they accept the referrals and schedule a visit by dinner on Friday. The Hub team has reassured Gerome a nurse is on the way. Upon arrival, a local examination determines no broken bones but a rather shook-up Gerome. Gerome is reassured and made comfortable, and a follow-up call is scheduled for the next day.


Gerome avoided the traumatic ambulance journey, long waits in A&E, and a two week stay in hospital. He’s a bit bruised, but he’s going to be okay.

The follow-up call cited some trip hazards in Gerome’s house, so a referral to the OT team was made. Additionally, it was cited that a walker would help Gerome stay stable at home, so a referral was also sent to the equipment team to forward a walker. This is a great help, as some of Gerome’s new medications can make him dizzy.

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How To Get Started