FEATURE All Together Now:
A Multi-disciplinary Approach To Care Tomorrow’s Care finds out more about the Sunderland-based All Together Better service, a collaborative initiative designed to enhance care across the city.
Care homes in Sunderland are now benefitting from a new city-wide programme designed to support residents and their carers, which comes as a part of the All Together Better service.
The Sunderland programme has seen community-based NHS nurses providing specialist assistance to people living in residential, nursing and extra care homes in a bid to reduce the amount of people falling ill.
The service hopes to provide those who do fall ill with quicker, more effective care so as to avoid them needing hospital care.
This initiative is part of All Together Better, a new service set up by Sunderland Clinical Commissioning Group; Sunderland City Council; Age UK Sunderland; Sunderland Carers Centre; local Hospital Trusts; pharmacies and therapies and local GPs in a bid to to reshape care in the city.
All Together Better is one of 14 multispecialty community provider vanguards set up by NHS England to relocate care, usually delivered in hospitals, out into the community. The vanguard model was recommended in the NHS Five Year Forward View, published last year, as a way to provide five million patients across England with more integrated, at home care.
As part of the Sunderland programme a team of community nurses are now providing visiting-support to care homes across Sunderland.
The scheme has also seen the nurses – who visit each of the city’s care homes roughly once a week – work with care staff to help manage
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illnesses or injuries effectively, spot the early signs of health problems, implement the right care to treat residents, and prevent conditions from worsening.
Debbie Burnicle, Deputy Chief Officer at Sunderland Clinical Commissioning Group (CCG), said: “The new care home nurse support was introduced after we looked at ways of targeting - and proactively supporting - those in the city with some of the most complex health and social care needs. We piloted this approach in the Coalfields area, saw the benefits and learned lessons that we have been
able to build into what is now a city wide approach.
“We recognised very quickly that, with that added layer of medical support, we could not only provide greater support during times in which people’s needs become exacerbated, but we could also spot the warning signs and prevent them from becoming unwell in the first place.”
As part of a multi-disciplinary team of professionals, operating in community- based groups, the scheme’s nurses assist care home staff to understand which residents require extra attention, support them with medical observations and, where required, provide necessary care or medication.
Working within a Community Integrated Team - five of which have been set up across Sunderland to put health and social care teams on the doorstep of the people they care for - the scheme’s nurses feed into a wider group of professionals, ensuring details of any care they provide are shared with those who provide more regular support to the person.
The nurses are also able to support residents, their carers and families to put in place emergency healthcare plans (EHP) that can be followed if someone they look after becomes severely ill. The nurses work to understand the expectations and choices of each person they support, and assist with end of life planning, to ensure that the wishes of the person can be taken into account when that time comes.
For more information about the care home nurse teams, or the Sunderland vanguard programme visit
www.atbsunderland.org.uk.
www.tomorrowscare.co.uk
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