The Hospital-to-Home Journey: How Lilli Enables Smoother Care Transitions
Over 13,000 people in England are waiting to be discharged from hospital each day, according to NHS data, creating a bottleneck in the health and social care system for those in need of support.
For those who are medically fit to leave hospital, the journey home can often be more complex than anticipated. Care providers and local authorities must often navigate significant budget and resource constraints, limited real-time data and overwhelming demand.
Innovative solutions have been shown to help overcome these challenges, bridging the gap between hospital discharge, accurate assessments and home support. Remote monitoring technology bridges this knowledge and resource gap, providing the hard evidence care professionals need to make decisions about each patient’s requirements, speeding up assessment and discharge by an average of 16 days for each patient.
The Data
According to the Association of Directors of Adult Social Services (ADASS), in 2024 over 400,000 individuals were waiting for assessments or reviews while fit for discharge from hospital. This bed-blocking crisis, with a 164% increase in undelivered home care hours—despite a 15% growth in service provision, underscores the immense pressures faced by care teams.
What contributes to these challenges?
The chronic lack of accurate, real-time data available can often cause care misassessments, complicating the transition from hospital to home. Limited information at discharge can lead to the overprovision of care packages, not only driving costs up unnecessarily, but also diverting already overstretched resources from those who need them most.
Transforming the hospital-to-home Experience
Lilli’s non-intrusive technology empowers care teams with actionable data and insights into an individual’s daily life at home. Through leveraging AI and machine learning, Lilli monitors behavioural patterns and trends, enabling more precise and efficient care decisions, leading to improved care outcomes.
Lilli supports the hospital-to-home journey through:
- Real-Time Monitoring - Lilli’s sensors track daily activities, highlighting changes in behaviour that could signal health deterioration, or recovery progress.
- Evidence-Based Decision-Making - care teams get access to data and detailed insights, enabling them to tailor care packages. This can reduce the over-provision of care, ensuring optimal resource allocation, or the right-sizing of packages of care.
- Enhanced Efficiency: Lilli’s data-driven approach minimises guesswork, allowing frontline teams to focus on proactive care delivery.
Esther’s Journey - a care story
Esther, an older adult living independently, was admitted to hospital with a fractured wrist. After being declared fit for discharge, the D2A team recommended three daily visits alongside the implementation of Lilli. Over the following weeks, Lilli provided crucial insights:
- It identified Esther’s ability to resume independent activities like eating and drinking after her cast was removed.
- Behavioural changes and regular bathroom visits detected by Lilli signalled a UTI, which was promptly treated, preventing further complications.
After six weeks, the data demonstrated that Esther could live with less intensive support, enabling a reduction in her care package to a single daily visit. Lilli’s ongoing monitoring continued to provide peace of mind for Esther and her family, and also increased her ability to live more independently.
The Broader Impact of Lilli’s Technology
By incorporating Lilli into the hospital-to-home process, organisations have been shown to achieve:
- Quicker hospital discharges by 16 days, and reduced reliance on intermediate care beds
- Empowering individuals to remain safely at home, and decreasing the risk of care crises
- Improved accuracy in care package commissioning and resource allocation
- Significant cost savings of 25% per service user, and increased efficiency for frontline teams
Looking Ahead
The success of the journey home from hospital relies both on the human and the technological impact. Lilli enables people and care providers to have the insights needed to make the needed informed decisions in order to optimise resources and deliver better outcomes for individuals transitioning from hospital to home.
By addressing every critical gap in the discharge-to-assess process, Lilli not only transforms care delivery, but also supports individuals in regaining independence and confidence in their own homes.