Get Me Home Project

Cardiff, Vale of Glamorgan

Hear how integrated support is delivered across projects funded by the ICF and Transformation Fund to get people home.

Together, the projects work with an overarching aim of collaboration for improving the patient journey and providing integrated support to meet the needs of the individual. Making their transition from clinical care, through rehabilitation to independent living.


The projects include:

  • A single point of contact within the hospital for discharge and community-based services, removing duplication and inconsistency, and improving co-ordination and information sharing.
  • Age Connect Discharge Liaison Officers for Vale citizens and their families. Both teams use ‘What Matters’ conversations to trigger holistic, tailored support that meets the wellbeing needs of the individual, providing preventative interventions and supporting independent living.
  • Additional Community Resource Team support with funding for Physiotherapists, Occupational Therapists, Social Workers, Social Work Assistance, Third Sector Co-ordinators and domiciliary care support for step up and step-down care.
  • The Pink Army – a team providing a single point of contact for Cardiff citizens and their families. 

Video: Get Me Home: Pink Army

Get Me Home Plus

The Get Me Home Plus care model helps people in hospitals who have been assessed as needing higher level support to get the care they to return home. Being at home helps people recover faster as people feel more comfortable and are able to move around more easily and be in a familiar environment with their friends and families.

Find out more about how integrated support is delivered 

COVID-19 meant we haven’t been able to collect all the data we wanted to, but the project.

  • Reduced need for social care packages
  • Reduced length of stay
  • Improved communication between different services
  • Fast discharge from hospital and no delayed discharge

Service user

“… they supported me whilst I waited for a room in a care home where I now have what I need –  electric chair/bed. And now I can maintain my independence.”

Occupational Therapist

“… has been great providing to patients on the ward to support safe discharges. There is improved communication on the ward between health staff and social services in regards to waiting on information around package of care and communication to social workers.”

Accommodation Solutions

We have continued to support 12 flats for the short-term use of local citizens to assist with hospital discharge or prevent admission.

Whilst the team received a lower number of referrals than normal due to COVID-19, they were still able assist 142 people in their discharge from hospital at an estimated saving of £380,485.

Our Priorities


We want every child in Cardiff and Vale to have the opportunity to thrive. Our work focuses on children in vulnerable situations and the services that support them.


We know how hard it can be to find help when people need it the most. We want to make sure there is community support to help people stay as healthy as possible so they can carry on doing the things that matter most to them.


As a Partnership we have worked together with people with a learning disability, their families, carers and the third and independent sector to produce a clear direction for the planning and delivery of adult learning disability services across the region over the next five years.

Case Studies

Alison Law 

   Improvement and Development Manager, Joint Commissioning 

  • Project management across the partnership to enable the alignment and joint commissioning of services, which includes shaping the market, regional commissioning strategies, contracting and quality assurance.
  • Programme manager for ICF Capital fund 

Meredith Gardiner 

Job Title

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