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Well Connected

Developing Out Of Hospital Care

We will develop an improved out of hospital care model by investing in sustainable primary care which integrates with community based physical and mental health teams, working alongside social care to reduce reliance on hospital and social care beds through emphasising “own bed instead”.

For Example:

There will be local neighbourhood teams across the county. Teams are in different stages of development but Community Nurses, Enhanced Care Teams, Promoting Independence, Community Therapists and other closely aligned services will join together to work in a much more collaborative way with social care and GP colleagues

The teams will wrap around their identified cohort of patients who are vulnerable or at greater risk of hospital admission. Ny providing more proactive and responsive support the aim is the reduce reliance of beds, and keep people well at home for longer

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