Integrated Transfer of Care Hub (Discharge)

The Integrated Transfer of Care Hub (ITOC) is a multidisciplinary team made up of health and social care professionals, therapists, discharge coordinators and third sector agencies. The aim of the hub is to promote and support a safe and timely discharges from hospital.

When you’re ready to leave hospital, we want to make sure the next step in your recovery is safe, smooth, and well-supported. That’s where the Integrated Transfer of Care Hub (ITOC) comes in.

The ITOC is a team of professionals from across health, social care, therapy, and community services who work together to help plan your discharge from hospital. Their goal is simple: to make sure you leave hospital when it’s safe to do so, with the right support in place.

What the ITOC Team does:

• Supports safe and timely discharges from hospital
• Works closely with hospital staff, patients, families, and carers
• Helps arrange any care or support you might need after you leave
• Makes sure everyone involved is working towards the same goals
• Follows the national “home first” approach, aiming to help you return home if it’s safe

Why leaving hospital matters

Once you’re well enough, staying in hospital longer than needed can slow down your recovery. It may reduce your independence, cause muscle weakness, or increase the risk of infection.

That’s why we start planning for your discharge as soon as you’re admitted, so you're ready to leave safely and confidently when the time comes.

What to expect during your stay

• Estimated Date of Discharge (EDD): On your first day, we’ll give you an idea of when you’re likely to leave. This may change depending on how your care progresses.
• Working Together: Your ward team, including nurses, doctors, therapists and discharge coordinators will keep you and your family involved in every step of the plan.
• Questions? If you or your carer have questions about leaving hospital, ask to speak with the Discharge Coordinator on your ward.

What happens when you need extra support

If the team on the ward thinks you’ll need some extra help after leaving hospital, they’ll refer you to the ITOC team. There are two ITOC teams, one based at Pinderfields Hospital and one at Dewsbury and District Hospital. Which one you are referred to depending on where you’re receiving care.

The ITOC team will:

• Review your needs
• Work with your hospital team to plan the next step
• Make sure any support is in place, whether that’s at home or elsewhere

If going straight home isn’t possible right away, you may need a short stay in a community bed for further assessment or recovery before returning home.