Overview
Community Flow has been operating in Northern Devon since July 2022. The service supports patients discharged home from hospital with little or no independent support, and who have been identified by clinical or care staff as potentially find managing their recovery and ongoing health and wellbeing difficult. This is usually due to issues in their wider lives. The Community Flow Team are embedded within the three Community Health and Social Care Teams across Northern Devon – one worker per locality team.
Recently Community Flow won the award for ‘Using money wisely’ at the South West Integrated Personalised Care Awards 2025.
Some individuals find it more difficult than others to manage their recovery and ongoing health and wellbeing following a stay in hospital. This can apply to both patients on discharge….
The service supports adult patients who have recently been discharged from North Devon District Hospital. Usually these are on either discharge pathway 0 or pathway 1…
The main aims of Community Flow are: to the Individual – improve health and wellbeing, to the Trust – improve patient experience of hospital discharge, to the System – support sustainability of ….
Three Community Flow Caseworkers are deployed to work in the three Health and Social Care Community Teams in Northern Devon – one worker per team. They provide the following….
Community Flow is funded by the One Northern Devon LCP through the One Devon Integrated Care Board’s population health budget. Part of this budget is devolved to the local LCPS to….
Recent evaluation of Community Flow by the RDUH Business Intelligence Team showed that during 2024/2025 it reduced the admission rates of patients supported by 41%. It also showed that the return on investment….
The service is provided by the RDUH in partnership with Encompass Southwest who employ and manage the three caseworkers. Following a recent tender process they will continue as the provider for 2025/2026….
The problem we are addressing
Some individuals find it more difficult than others to manage their recovery and ongoing health and wellbeing following a stay in hospital. This can apply to both patients on discharge pathway 0 (those with no additional health or social care needs) and patients on discharge pathway 1 (those who require support from health and/or social care services to facilitate their recovery. This might include reablement, therapy, or ongoing nursing care). Often this is due to factors in their wider lives – such as relationships – loneliness & isolation, or issues with accommodation and finances. These needs often fall outside he remit of health and social care colleagues – but they can impact their ability to support clients patients to manage their recovery. Community Flow aims to support patients to address these issues – which enables patients and clinical colleagues to achieve better health and wellbeing outcomes.
The intended beneficiaries
The service supports adult patients who have recently been discharged from North Devon District Hospital. Usually these are on either discharge pathway 0 or pathway 1.
What we want to achieve
The main aims of Community Flow are:
To the Individual:
- Improve health and wellbeing
- Reduce the risk of health inequalities
- Reduce loneliness and enables the individual to feel connected to their community
- Increase their control over everyday life
- Looks to maximize income opportunities
- Looks to maximise independence
- Addresses poor housing/accommodation issues
To the Trust:
- Improve patient experience of hospital discharge
- Reduce likelihood of unnecessary re-admissions to hospital
- Enable faster and safer discharges for people medically fit where possible
- Support community teams to be able to focus on clinical needs
- Connect Trust staff with others involved in their patient’s care
To the System:
- Support sustainability of clinical health interventions
- Join up and improve efficiency of healthcare interventions
- Reduce the cost burden of health inequalities
- Reduce likelihood of social care costs (areas worked on link to Care Act 2014 outcomes)
- Contribute to hospital flow with the benefits to the rest of the system that that brings
How we want to achieve it
Three Community Flow Caseworkers are deployed to work in the three Health and Social Care Community Teams in Northern Devon – one worker per team.
They provide the following:
- Person centred care: A primary focus on what is important to that person within the above areas – goals/wishes rather than ‘needs’ – a move from ‘what’s the matter with you? – to what matters to you?’
- Assertive outreach model: 1:1 caseworker solution focussed support over a six-week period – a focus on relationship building and understanding – then working together to solve problems. Turning ‘needs’ into ‘goals’
- An asset-based approach: Looking at the potential resources a person has within their life as well as their own strengths
- Community partnership: Linking the individual into their community and actively supporting them to access opportunities (As distinct from basic signposting, which often is not enough to secure engagement and commitment)
- Integration and Collaboration: Where needed, pulling together and co-ordinating a team around that person – rather than multiple separate and independent interventions
- Support with speeding up discharge where possible. When non-clinical/care factors are delaying a discharge the Community Flow Team can help address these issues.
Timescales & Funding
Community Flow is funded by the One Northern Devon LCP through the One Devon Integrated Care Board’s population health budget. Part of this budget is devolved to the local LCPS to deliver programmes of work which tackle health inequalities – and Community Flow is one of these programmes.
We currently have funding until 31st March 2026 for 2.8 Full Time Caseworkers
Evaluations & Results
Recent evaluation of Community Flow by the RDUH Business Intelligence Team showed that during 2024/2025 it reduced the admission rates of patients supported by 41%. It also showed that the return on investment was a minimum of £3.61 for every £1 spent and it is estimated this is likely to be closer to £4.21 for every £1 spent.
The 2025 BI Report can be found here.
The most recent Quarterly Report can be found here
The 2023/2024 Annual Report can be found here.
Who has been involved?
The service is provided by the RDUH in partnership with Encompass Southwest who employ and manage the three caseworkers. Following a recent tender process they will continue as the provider for 2025/2026.
The workers are based work as part of the RDUH/DCC Adult Health and Social Care Community Teams in North Devon.
The One Northern Devon LCP provide the funding for the project and Community Flow is part of their health inequalities programme of work for 2025/2026.