An innovative programme that is supporting people who have the poorest health in the city is up and running and improving lives.
All Together Better (Sunderland) is a partnership bringing together health and social care professionals as well as other local support agencies to help improve services for people who need a little bit more help than most with their health or social care needs.
They are usually older people and those who have several ‘complex conditions’ – lots of illnesses or disabilities and may also already be getting support from health and social care services or are being looked after by family or friends.
But when this support is not enough, for example if they get an unexpected illness that makes their condition worse, they can get extra help from the All Together Better team.
One of the main aims of the partnership is to help people stay as independent as possible at home or make sure, when they are ready to be discharged from hospital, they have the right care and support to help them to get back on their feet.
Most people would rather be at home than in hospital and Sunderland is leading the way to show how health and social care teams can work successfully together to make sure that, when they need it, the most vulnerable people in society get all the care and support they need, at the right time.
Those working together on All Together Better include doctors; nurses; social workers; social care (home assessment and equipment); Age UK Sunderland staff and volunteers; as well as a range of other health professionals like pharmacists and therapists.
An important part of the partnership is the Sunderland Carers Centre that offers a range of information, advice and support to family members and friends who look after others in a caring role.
All Together Better is working with all the care homes in the city to offer the same level of joined up service, delivering proactive care to vulnerable residents when they need it most.
To find out more about All Together Better, visit www.atbsunderland.org.uk
On the website you will find information about the partnership, who is involved, some real-life stories about people who have already benefited by the new, joined up service, as well as see a short film that describes it.
You can also get involved, with events being held across the city that will share more information about the service and give you the chance to offer your views.
The partnership is part of the ‘Vanguard’ or New Care Model programme, funded by NHS England to help transform services, making them more effective and efficient for local people.
The work being carried out in Sunderland will be shared with other areas of the country to guide them on how to deliver a new, joined up way of working.
WHO IS INVOLVED?
Recovery at Home
Recovery at Home is a unique service that brings together a range of health and social care professionals as a team to respond quickly by providing short-term care to people at home. ‘Home’ might mean residential or nursing care.
Together the team help prevent people going into hospital if they don’t need to be there and support people who have been discharged from hospital, providing a little extra help to get them better.
The team offers a 24-hour service, based centrally at Leechmere in Grangetown, and covers the whole city. Within a few hours the team can assess patients’ needs; provide treatment if necessary and put in place additional care and support if required.
As well as doctors; nurses; health professionals; social-workers; Age UK Sunderland’s Hospital Discharge staff and care workers.
Recovery at Home also has two community-bed units for people who need extra support but aren’t poorly enough to be in hospital. The units – one in Houghton and one in Town End Farm – are staffed by nurses and other healthcare professionals.
Community Integrated Teams
Five multi-skilled ‘community integrated teams’ (CITs) are in place to provide an effective response to vulnerable people, in poor health, with the most complex needs.
We know just 3% of the city’s population use around 52% of the NHS resources alone, and this doesn’t include the additional pressures on other public services like social care.
The majority of people the teams help are older people so need a lot of support. The CITs work to help people to stay as independent as possible in their own home or care home, delivering a joined up service on their doorstep.
Based in key localities in the city (Bunny Hill; Hendon; Houghton; Grindon and Washington) the teams are district nurses, community matrons; general practitioners, practice nurses, social care professionals, Age UK Sunderland link workers and carers support workers.
Key to the effectiveness of the teams is the development of multi-disciplinary team’s (MDTs).
They bring together a range of specialists including CIT members by GP practice to discuss the best possible course of action for the patients identified as needing the most support. Each area has an MDT co-ordinator to make sure meetings are run effectively.
Enhanced Primary Care
While your family doctor (GP) is involved in both the important new services outlined above, a group of GPs are working together to look to the future and develop services further including a wider group of patients cross the city, as well as those in the poorest health.
This includes how technology can be used to deliver the best care possible for patients in their homes; how to provide even more services directly in the community and outside hospitals; and how community services can work more closely with other support organisations.
Email firstname.lastname@example.org or write to All Together Better (Vanguard) team; Sunderland Care and Support, Carrmere Road, Sunderland, Tyne and Wear SR2 9TQ