Enhancing patient flow through Trusted Assessments in County Durham

Overview

In 2018, County Durham Care Partnership commissioned Xyla to support County Durham & Darlington NHS Foundation Trust (CDDFT) in addressing increasing pressures on patient flow and enhancing hospital discharge processes.

This collaboration formed the basis of a strong and evolving partnership, which progressed in 2020 with the introduction of a Trusted Assessor (TA) model. Designed to streamline discharges from hospital to care homes, the model ensures timely, person-centred care transitions.

Service specification

Xyla clinicians carry out assessments on behalf of care homes, either remotely or in person, based on each patient’s needs.

The TA service supports all funding types, including social care, self-funding, Continuing Healthcare (CHC), Fast Track, and Section 117 after care, and also accepted referrals for County Durham residents in neighbouring NHS trusts or Intermediate Care (IC+) beds.

This service was commissioned to support patients often waiting in Hospital for care home assessments, leading to discharge delays and increased bed days. The Xyla TA service allows care home managers, hospital and social staff time to focus on the tasks they need to complete knowing that the assessment will support the admission of the patient. Introducing a centralised, clinically-led assessment model reduces delays, improves placement decisions, and enhances patient outcomes through a more coordinated discharge process.

Xyla’s Impact

Xyla’s (TA) model has reduced discharge delays across CDDFT by delivering impactful, timely, clinically led care home assessments. This has improved patient flow, eased pressure on hospital beds, and ensured safe, sustainable placements.

As a result, we have seen a reduction in re-admission rates, and positive feedback from care homes reflects strong continuity of care and stakeholder confidence. Regular audits and feedback support continuous improvement. Xyla’s high-performance model delivers speed without compromising quality.

By implementing this approach, County Durham has achieved faster, safer, and more coordinated discharges, strengthening system flow across health and care services.