Derbyshire Team Up Pathway
Developed from the Erewash Frailty and Acute Visiting Services (from 2013), the PCN-led Team Up service is an ambitious programme operating across the whole of Derby and Derbyshire. The service aims to create integrated teams across health and social care who see housebound patients in their neighbourhoods.
The programme focuses on the large frail population in the area, who are at greater risk of hospital admission and poor outcomes if they remain unvaccinated against seasonal illnesses. But with around 30,000 patients served by the Pathway, managing this is a challenge for separate individual practice capacity.
Since 2019, the Pathway integrates many services traditionally provided by multiple providers including:
- urgent community response (Ageing Well)
- enhanced health in care homes including vaccinations (Ageing Well & PCN DES)
- anticipatory care
- hospital discharge pathways
- acute home visiting service.
The model allows for planned and preventative care to run alongside same-day response services, allowing for a connected approach to housebound and care home patients with multimorbidity.
Through the PCN-led Team Up pathway, each PCN in Derbyshire has contracted for support delivering vaccinations in care homes and to housebound patients experiencing frailty as part of the Ageing Well branch of the pathway.
Each PCN has selected their preferred delivery vehicle reflecting their local needs flexibly, delivering the best service output for their patients within their clinical capacity. This has significantly improved the service provided to patients, reduced the strain on practices, supported winter pressures and enabled PCN-led at-scale delivery to reduce variation in service across Derbyshire.
