WP3. Pilot Process Evaluation of Digital Post Hospital Discharge and Reablement Services.
Work Package 3 evaluated the processes and practices of localized Technology Enabled Care Services (TECS), focusing on one specific type of service: digitally enabled Post-Hospital Discharge and Reablement Services (PHDRS) for older adults. This service model was chosen as a novel service prioritised across all three local authority and ICB partners in the project. This pilot evaluation was conducted across three regional sites in England; Bristol, North Somerset and South Gloucestershire Integrated Care Board, Middlesbrough Council, and Oxfordshire County Council. The pilot study addressed a key priority for local health authorities seeking to reduce hospital stays, increase discharge rates, ensure discharge happened earlier, and reduce costs related to delayed discharge and social care service usage. Following UK Medical Research Council guidance for evaluating complex health interventions, researchers conducted semi-structured interviews with strategic leads in each service and analysed pilot project service data. The project used a framework analysis model too map out how post hospital discharge services, spanning NHS trusts, local councils, call centres, and private care providers provided their services.
The evaluation identified two distinct service delivery models across the three regions, with service models being shaped according to local priorities and operational goals. In the Bristol region, a centralized regional model was adopted which spanned multiple local authorities, with services being provided through a single private health and care provider. This regional approach ensured the delivery of a standardized care model, which was felt to reduce and prevent discharge delays caused by varying local council. The second model deployed in Middlesbrough and Oxfordshire took the form of more conventional services solely located in a single authority, delivered by their internal local authority technology enabled care teams. Despite these structural differences, all three sites offered similar service terms: free provision of technology for an initial eight-week reablement period, after which service clients could move to a paid plan, or discontinue the service.
The technologies offered in all three sites were largely standard telecare services, using digital pendant alarms, fall detectors, motion-sensor lights, bed/chair sensors, and passive activity monitoring systems rather than deploying technologies or services that have been custom-built for post-discharge care. Certain regions also piloted newer innovations, such as acoustic monitoring in care homes and voice-activated digital assistants and aimed to deploy these technologies into future iterations of services. Each service had plans to expand technology offers but were dependent on a changing policy landscape and availability of resources to deploy new technologies. Ultimately, the findings highlighted that successful digital service models for post hospital discharge depends as much on cross-agency coordination, service ownership, and equitable access as it does on the devices themselves. The researchers conclude that future evaluations must track these organizational dynamics and delivery pipelines in greater detail to determine the long-term effectiveness of digital post-discharge care.
The findings of this work package have now been expanded into a new NIHR funded DIALOGUE research project (DIALOGUE 2.0) detailing the ongoing delivery of post hospital discharge services using digital technologies. .
More information about the pilot evaluation can be found in:
Gibson, G., Lariviere, M., Steils, N., Marston, H., Wilson-Nash, C., Lynch, J., Brittain, K., Henderson, C., Thorn, J., Worthington, J. and Pike, K., (2025). DIALOGUE: Digital care technologies for social connection, care and support of older adults. Final Project Report. NIHR Open Research, 5, p.95.