An ambitious project has been launched in Staffordshire in an attempt to reduce the level of non-elective admissions to the University Hospital of North Staffordshire by almost 12,000 over the next three years.

Commissioners, the acute trust and the local specialist community services trust have agreed a deal which, it is hoped, will lead to patients at higher risk of admission being identified earlier, with joint teams being used to give them better integrated support in a bid to reduce admissions.

The Staffordshire and Stoke-on-Trent Partnership Trust, the largest provider of integrated health and social care services in the country, is leading the work. It has received £7m of funding from North Staffordshire and Stoke-on-Trent CCGs to deliver a reduction of 2,500 non-elective admissions by April 2014 and a total of 11,900 by 2016.

It will use the cash to recruit more district nurses and boost home based intermediate care while increasing access to “step up” and “step down” beds in its five community hospitals.

Local integrated care teams of health and social care staff are providing joined up support to frail, older people and those living with long term conditions. Nursing, social care, physiotherapy and occupational therapy staff are working in community intervention teams to offer short-term support to patients.

In September the partnership trust launched “the hub”, a dedicated clinical telephone service to assess some referrals from GPs and health professionals to see if they definitely required hospital admission and co-ordinate primary and community care services.

The number of referrals to the hub increased from 378 in September to 649 in October. Of the October referrals, 90 per cent of patients remained “in their usual place of residence”.

Partnership trust medical director Doug Wulff said: “Our integrated model of care works on the basis that patients and potential patients undergo a risk assessment based on a variety of social and health factors which places them in a group, based on their actual or predicted level of need.

“By carrying out this assessment, care can be targeted not only at users with an immediate need, but at those who are highly likely to have future needs, thus ensuring that independence can be maintained and escalation to hospital care is avoided.”

Mark Hackett, chief executive of the acute trust said: “Our system ambition is to reduce emergency admissions by 12,000 over three years at the trust, which is a level of reduction that has never been seen before internationally.

“This reduction, if achieved, will give us the opportunity to focus on reducing the current bed [occupancy] to at least 92 per cent and ensure non-elective admissions do not impact on our elective work.

“By doing this we will improve the care that patients receive and help to stabilise and contribute to the trust’s long-term vision and strategy.”

A spokesman for both Stoke-on-Trent and North Staffordshire CCGs said: “Our health economy currently has too much reliance on bed-based services when community based services are often better placed to meet the needs of patients with long term conditions.

“Both CCGs are working with our partners to look at transforming the whole health system.”