We work with health boards to deliver innovative, responsive and person-centred services that ease pressure on acute care, support timely discharge, and promote independent living.
Our integrated model combines technology, highly skilled, compassionate support, and community-based care to deliver measurable outcomes for patients and systems alike. Focusing on proactive and preventative care, we deliver the right support at the right time, to ensure better outcomes for patients and a more sustainable health and care system.
We are a Teckal-compliant organisation, allowing public sector bodies to award contracts directly without competitive procurement. This streamlines commissioning and ensures continuity of service delivery.
Home from hospital service
Our home from hospital service is designed to facilitate patient discharge and support the transition from hospital to home with ease, ensuring continuity of care and reducing avoidable readmissions. Offering 24/7 support and rapid response, it frees up hospital resources while empowering individuals to recover in the comfort of their own homes.
Blue Army
Embedded within hospital wards and emergency departments, our Community Wellbeing Officers work alongside hospital staff to assess patients, support discharge planning, and provide a vital link to community services. They assist, advise, support and signpost patients to appropriate care pathways, helping to maintain flow and reduce delays. The approach is simple: make going home safe, smooth, and stress-free. By combining practical help, emotional reassurance, and technology-enabled care, we can help patients regain independence and reduce pressure on hospitals.
Practical support and advice
Our officers provide clear information and guidance on social care and community services. They can:
Signpost to trusted third sector organisations, for example, MIND, Care & Repair and Age Cymru.
Provide lists of local services such as cleaners, shopping support, home help, and meal deliveries.
Help patients and families navigate social care processes.
Bridging care gaps
The team will arrange short-term emergency support to facilitate discharge for medically fit patients to help settle them back at home or while waiting for reablement or long-term care services to start. This ensures patients aren’t left without help during critical transition periods.
Technology Enabled Care
Before a patient leaves hospital, the team can arrange lifeline technology so that patients can return home with confidence – knowing that help is always just the press of a button away. This not only speeds up discharge but also gives patients and families reassurance that support is on hand 24/7.
Welfare and shopping
The team will arrange for our response team to carry out welfare visits to check on patients’ wellbeing following discharge. For those without immediate support, they can also arrange essential shopping visits.
Response team
Hospital transfers and discharge
The team assists with timely hospital discharge for medically fit patients, providing short-term care to help individuals settle back at home or until reablement or long-term providers are in place. This reduces pressure on the NHS and supports health and social care flow. The team can also provide safe and reliable transport to and from medical appointments or hospital discharge.
CIW-registered
The team are the first of its kind in Wales to be registered with Care Inspectorate Wales, allowing them to be able to provide the necessary care and support in the community. This also enables us to work innovatively with both health boards, as well as our local authority partners, offering flexible, person-centred support.
Rapid response
Patients are equipped with assistive technology such as lifelines, connecting them to our 24/7 monitoring centre. If concerns arise – such as sudden deterioration, a fall or other crisis – our team is dispatched immediately.
Skilled & compassionate care
Staff work closely with the ambulance service and are fully trained in:
First aid and basic life support
Manual handling
Dementia awareness
Clinical observations
Personal care
Medication administration
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The Problem: Delayed transfers of care (bed blocking) is costing the NHS |
The Solution: An integrated approach |
Proven Impact: Impact: cost avoidance |
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Telehealth
Remote monitoring for chronic conditions
Our telehealth service enables patients to monitor chronic conditions such as cardiac health, lung function, and chronic obstructive pulmonary disease (COPD) using a range of health equipment paired with a mobile app. Readings are automatically shared with healthcare professionals, allowing for early intervention and personalised care. This supports patients to manage long-term conditions from the comfort of their homes.
Orthopaedic prehabilitation support
We can support health boards in delivering prehabilitation services for patients awaiting orthopaedic or other surgery. Using digital platforms and remote monitoring tools, we can help optimise patients’ physical and psychological wellbeing before their procedures. This approach can reduce complications, improve recovery outcomes, ease pressure on secondary and community services, and crucially, avoid cancellations of operations due to patients being unfit for surgery.
Scalable across pathways
The service model is designed to support:
Elective surgical pathways
Chronic disease management (e.g. pulmonary rehabilitation, cardiac rehabilitation, long COVID)
Rehabilitation and recovery at home
Hybrid care & wearable technology
Our approach blends virtual and in-person care, supported by wearable devices that monitor blood pressure, oxygen levels, activity, sleep and mobility. This enables real-time data collection and proactive support, helping to identify risks associated with frailty and falling and identifying early signs of deterioration as well as reducing hospital admissions.
Virtual hubs & integrated care
We are exploring the development of regional virtual prehabilitation hubs to support patients across organisational boundaries, enhancing collaboration and continuity of care.
Driving digital transformation
In partnership with health and social care across Wales, we are leading an ambitious agenda for digital transformation. We have already made the digital switch with our TEC monitoring platform, this ensures full compatibility with next-generation TEC devices, and our open API architecture allows seamless integration with third-party platforms:
Central hub functions for workforce mobilisation
Video consultations and triage
Multi-disciplinary team communication
Virtual hospitals and rehabilitation wards
Innovation management for testing new products and services