All Together Better - Recovery at Home - The Vanguard way

This great animation that explains how the Recovery at Home service works, and how professionals come together to make sure the people who need the most care are helped to stay as independent as possible, and living in the place they love – their home.

Recovery at Home is an important part of All Together Better, designed to greatly improve the care offered to people who need it most. Recovery at Home operates 24 hours a day, seven days a week, ready to respond quickly to provide support during times of illness or if someone experiences an unexpected change in their condition that could develop into a crisis.

The team – based centrally in one location at Leechmere, Grangetown – aims to support adults who live in Sunderland, who are registered with a Sunderland GP and need short term health and or social care support, that can help to keep them living at home, with care wrapped around them while they’re at their most vulnerable.

Support is tailored to a person’s needs and can be any combination of a short term care package, from nursing to therapy to get them back on their feet without having to be hospitalised or needing long term care. GP support is also available within the service.

Through Recovery at Home, those who need greater support while they’re getting back to normal after a short term condition can also be provided with bed-based care, meaning more intensive support can be offered in their own home, including residential or nursing care homes. And those who need to be in a fully supported environment will be given all of the support and advice they need to get them ready to return home and live independently.

This centralised team gives carers, GPs, health and social care staff, as well as other agencies, like the police, an invaluable single point of contact for some of the most vulnerable people in our communities who are at greatest risk of hospitalisation.

Student nurses are learning about an innovative new care model, that is transforming the way health and social care professionals look after Sunderland’s most vulnerable people.

Six students from Northumbria University have joined Sunderland’s newly formed Recovery at Home team, which aims to provide short term, interim care to those in the city who need the most support due to illness or injury.  There are 24 more student nurses working as part of All Together Better – a wider care programme of which Recovery at Home is one part.

The Recovery at Home students – Bethany Cooper, Bethan Harris, Paige Williamson, Philippa Hall, Rebekah Fish and Vicki Martin – are based at the new care hub in Leechmere, and are working as part of a multi-disciplinary team of professionals, that includes doctors, nurses, pharmacists and reablement staff.  Recovery at Home supports people when they leave hospital, putting in place a care programme to get them back living independently at home, as well as providing urgent care to those who are experiencing short-term spikes in their health or social care needs.
Rebekah Fish, 23, who is in the middle of a seven-week placement with the team, as part of her second year in Adult Nursing Studies, said: “I feel like I am learning a huge amount, and it has been really interesting to be part of this new way of working in Sunderland and to see the big difference it is making out in the community.
“The support people are getting in Sunderland thanks to Recovery at Home is totally focused on the person, and you can see the difference it is making to their lives when you go out to their home to visit them.  And for the teams who care for people in the city, it is fantastic to be able to sit together, as professionals with different skill sets and areas of expertise, to work together to treat the person in the best way possible.”

Third year student Vicki Martin, 34, is completing a longer, 20-week placement with the Recovery at Home team.

Vicki, from Peterlee, said: “The skill set within the Recovery at Home team is immense, and by working with colleagues across lots of disciplines, I feel like I am learning about lots of different things.

“Being community based means that we are visiting lots of different people in their home environment and learning about them as people, and that can only make for improved care.”

The student nurse team work with qualified nurses, and health and social care professionals to make initial assessments and to provide ongoing care.  The Recovery at Home team is contacted mainly by concerned health care professionals, if they think that a person needs additional support at home while they recover from an illness or injury.  A care team will then be dispatched from Leechmere into the community, to assess the person and provide the right care and support at home, until the person is well enough to live independently again.  A new information sharing system means that all the care delivered to the person is recorded and shared with those who normally provide care to that person.
“This way, you really do get a holistic overview of each person you visit, and that means that the care offered is 100 per cent tailored to their needs.  It’s great to see that Sunderland is doing things a little differently, and as a soon-to-be-qualified nurse, it’s nice to see care moving in this direction,” added Vicki.
The Recovery at Home team is part of a new programme, All Together Better, which aims to wrap care around the most unwell people in Sunderland, to ensure that they remain as independent as possible, and out of hospital.  The programme is funded by NHS England, and is known as a vanguard – a pioneering new pilot that is testing new and innovative ways of providing care to people across the country.  Each vanguard site will put in place a programme that responds to its area’s specific needs and challenges, and in Sunderland, All Together Better aims to address stats that show the frailest three percent of the population are using 50 per cent of NHS resources.

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