1. Sunderland MCP Vanguard

2. Before Vanguard: GPs operating independently with little influence on community services and over discharge planning. Hospitals paid based on activity with little incentive to work with other providers across pathways to reduce demand. Mental health, social and community care were delivered independently of each other. Difficulty navigating around services, with confusion around points of access. Most at risk patients were not supported and “bounced” around the system. Imbalance of activity between acute admission avoidance and discharge facilitation in the Intermediate Care Services. Patients did not feel involved in their own health and social care needs.

3. Risk Stratification approach: Population cost pyramid: Top 3% of patients drive 50% of cost in Sunderland Population cost segmentation, secondary care, community and mental health spend, 2013 1

4. The Care Model

5. Community Integrated Team: North Locality

6. Community Integrated Teams Co located Teams MDTs Shared Learning Governance Training needs analysis Shared training

7. The Recovery at Home Service broad objective is:- 'To provide care and support to individuals to remain at home in the community either by avoiding unnecessary admission into hospital or residential care, or by facilitating early discharge from hospital.’ A fundamental hospital discharge and readmission prevention service focused on maximising peoples independence The starting point for the Recovery at Home Service is that individuals do not want to be admitted inappropriately to hospital or to residential care but wish to receive care at home.

8. Recovery at Home

9. Current State In April 2015 both teams moved bases and co-located to the Leechmere site Integration of both teams with several service providers to create an integrated Health and Social Care Service covering the City of Sunderland. The creation of a single point of access 24/7 This Service is called Recovery at Home and is available to anyone over the age of 18, who lives in the City of Sunderland or who is registered with a Sunderland GP

10. Recovery at Home includes the following integrated services Flexible Community Beds Rapid Response Homecare service Tele-Care The Hub Intermediate Care Team Urgent Care Team Pharmacy Rapid Access to Community Equipment Services Out of Hours GP service – co located North East Ambulance Service

11. First Contact in the Community Primary aim of the Nursing element of the service is to assess, diagnose and treat acute illness and injury at home acting as first contact which may prevent an admission to hospital 24 hours, 7 days a week, 365 days a year Nurse Practitioner led service, timely response to referrals, normally within four hours dependant upon triage. Full history and clinical examination of all patients, assessment may include clinical observations, bloods, ECG, urinalysis, stapling/gluing wounds, dressings, catheterisation, IV antibiotics Treatment at the point of contact for example, Antibiotics, Nebulisers, Steroids, Analgesia Reviews until the patient is stable, then step down to community/primary care partners and associated healthcare providers

12. Fleet

13. Medication, PGD’s, Prescribing

14. Equipment

15. Venepuncture, Cannulation, IV Therapy

16. Wound Management

17. Resuscitation

18. As an integrated service we have the ability to determine the most appropriate outcome in partnership with the patient. The access to step up community beds is seamless, eg place of safety, falls, confusion, monitoring. Implementation of short term packages of care to support people at home in times of crisis Access to community equipment is on site Access to Occupational Therapy and Physiotherapy as part of the support package at home Acts as a resource to support City Hospitals with discharge planning Seamless Working across Health and Social Care

19. Service Development Point of Care testing Community EMISweb Care Home Tablet links Development of OPAL in-reach service GP working as part of Recovery at Home New Ambulatory Care Pathways, COPD, DVT, Cellulitis North East Ambulance Service integration

20. Questions