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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”.


Neighbourhood teams:

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There will be local neighbourhood teams across the two counties. 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. By providing more proactive and responsive support the aim is the reduce reliance of beds, and keep people well at home for longer. Click here for more information. 


Integrated approach being undertaken for the respiratory pathway in Worcestershire – test and learn opportunity to explore whole system approach to resources and movement of workforce/delivery.


We have launched a new Mutli-disciplinary footcare team (MDFT). There are currently 35,000 people with diabetes in Worcestershire, with 2,000 new cases each year. Having diabetes means you have a greater risk of developing foot problems. If these problems are not treated properly, they could lead to more serious conditions such as foot ulcers, infections, gangrene and at worst case, amputation. The aims of the MDFT are to; Provide improved access to services around the county, reduce admissions and length of stay in hospitals, reduce the number of minor and major amputations carried out for diabetes foot disease.


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