Seamless transfer of care from hospital into the community requires consistent application of optimal handed care principles across the system. Consistency across assessment, equipment provision, workforce competence, and governance ensures that patient safety, independence, and system efficiency are sustained beyond the boundaries of one care setting.
Multiple best practice examples are available in England where Local Authorities, working with people and care providers, have implemented and embedded optimal handed care in the community. Following actions are a result of learnings from such areas.
Despite initial concerns, patients and families were generally accepting of reduced care packages as long as care quality remained high. The shift to Optimal Handed Care was found to improve patient empowerment and independence, as well as the quality of interactions."
F1. Embed optimal handed care approach consistently across all community pathways.
This can be achieved by:
- Hospital discharges: Work closely with the hospital discharge teams to ensure people with potential for OHC are referred and discussed early during the discharge planning process.
- Community referrals: Enable care providers, social workers, or family members to trigger OHC reviews where a person’s function or dependency changes. Introduce simple online referral tools to support timely submissions.
- Rehabilitation and reablement alignment: Embed OHC assessment within and rehabilitation pathways to reduce dependency, promote independence, and prevent unnecessary long-term care escalation.
F2. Strengthen integration between Occupational Therapists (OTs) and Social Work Functions to ensure that OHC assessments are clinically robust, person-centred, and statutorily compliant through close partnership between OTs and social workers (SWs)
Most care home residents are assessed by social workers, not OTs. The sector tends to take a risk averse approach."
This can be achieved by:
- Joint assessment protocols: Develop a shared OT-SW assessment process where both professionals undertake joint visits to assess function, environment, and care needs. Record findings jointly within a single shared assessment document.
- Brokerage integration: Ensure brokerage teams use the joint OT-SW assessment as the definitive document for care commissioning and package adjustments, reducing duplication and delays.
- Shared accountability and governance: Establish joint performance measures (e.g., timeliness of OHC implementation, outcomes achieved, reduction in double-up care) monitored through local governance frameworks.
- Co-location and communication: Where possible, co-locate OTs and social workers within the community to enhance joint working, reduce siloed decision-making, and promote shared understanding.
F3. Embed a culture of responsiveness and empowerment across community, enabling timely intervention, flexibility, and person engagement.
This can be achieved by:
- Rapid response pathways: Create community response protocols allowing OHC assessors to visit within 24–48 hours when risks, carer strain, or dependency changes occur. This could include an immediate virtual triage and advice followed by a visit, if required. Note that a person’s safety should always be prioritised.
- Embedding visits and coaching: Implement embedding visits to coach care staff in real time, build confidence, and reinforce safe technique. Use “stand-back” trials to demonstrate that tasks can be safely completed by one carer where appropriate.
- Flexible implementation: Allow for phased reduction to optimal handed care support, ensuring confidence and safety are established before full transition.
- Motivational and empowerment techniques: Train practitioners in motivational interviewing and person empowerment, helping people understand the benefits of OHC and how active participation supports recovery and independence.
F4. Manage reluctance or refusal of OHC by providing a clear, safe and ethical framework for addressing concerns or refusal of OHC by individuals, families, or providers.
This can be achieved by:
- Understanding the reasons: Understand the reasons for reluctance or refusal with an open mind, considering individuals’ wishes. Adjust the care plan accordingly to address valid concerns.
- Open communication: Explain the principles of OHC clearly — emphasising safety, independence, and dignity. Address misconceptions that OHC equates to cost cutting.
- Trial periods: Offer structured trial phases with follow-up review dates and defined safety measures. Use these to demonstrate efficacy and build trust.
- Multidisciplinary escalation: Where concerns persist, escalate cases to a multidisciplinary panel (OT, SW, provider representative, safeguarding lead) for review. Follow safeguarding processes if refusal places the person or staff at risk.
F5. Review current commissioning approach and explore meaningful way of incorporating optimal handed care into Provider contracts.
This can be achieved by:
- Understanding what works: Simply including optimal handed care into a commissioning contract does not necessarily enable or embed an optimal handed care approach into the way a contract is delivered by a provider. A cultural shift to enable a change in mind set across all stakeholders involved in delivery of care is required to embed an optimal handed care approach as business as usual.
- Value-based commissioning: Shift from purely cost-based commissioning to value-based commissioning, focusing on outcomes and the quality of care delivered. Incorporate measures of independence, well-being, reduced hospital admissions and reduced harms into provider contracts, making optimal handed care a key enabler to achieving these key performance indicators.
- Incentive schemes: Work with system partners to develop incentive schemes to reward providers who successfully implement an optimal handed care culture and practices and achieve desired outcomes. This could include enhance rate payments e.g., for reducing falls, promoting mobility and independence, and improving service user satisfaction. Example measures that indicate a culture sensitised to optimal handed care and the avoidance of harm and loss of independence could include reduced waiting times in ED, reduced deconditioning on the wards (measured via taking mobility scores upon admission and again at discharge), shifting demand to lower intensity discharge pathways, reducing the duration and intensity of care packages in the community.