Sunderland Community Integrated Teams Model and Recovery at Home General Practitioner Support to Intermediate Care Services

Sunderland Community Integrated Teams Model and Recovery at Home General Practitioner Support to Intermediate Care Services Delivery of GP Support to Community Integrated Teams to benefit patients with complex needs, and their carers, who are at risk of unwarranted health outcomes by enabling them to stay healthier for longer and deliver proactive and personalised care. Undertake risk stratification, identification of frailty and the coordination and delivery of MDTs with the delivery of: - Delivery of proactive care planning for those identified as part of risk stratification and sharing care plans with appropriate professionals and agencies. Undertake and coordinate regular MDTs with key agencies. - Undertake comprehensive geriatric assessments and training for frailty champions in all practices - Participation in the ongoing review of patient care and comprehensive evaluation of patients in care homes to understand the impact on urgent care pathways and the sharing of learning across the system. - Evaluation of high intensity users, ensuring appropriate care plans are in place. Delivery of Recovery at Home GP Service providing a 7 day GP visiting service at Farmbrough Court Intermediate Care Facility and the delivery of an on call service for clinical support and advice to the Recovery at Home Service. The service is being reviewed in 2024/25 as part of a wider review of Care Closer to Home services with the ambition to have a new model in place for 2025/26. On this basis and on the back of historical contract delivery, the intention is to issue a new contract under direct award C for 2024/25.