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THE MOST vulnerable people in Sunderland are being helped to improve their quality of life thanks to a new team delivering a more joined-up care service.

Age UK Sunderland’s Living Well Link team, created to provide support and the “human touch” for some of the city’s most vulnerable and unwell people, is up and running in the community.

The team of five are working with social workers from Sunderland City Council’s social services department, as well as medical professionals like district nurses, community matrons GPs, and colleagues from Sunderland Carers Centre as part of the newly formed Community Integrated Teams to deliver joined-up care that wraps around the person, as part of an initiative called All Together Better, that was launched this year.

The Living Well Links team has been appointed to offer a helping hand to people living with some of the most complex health problems, securing the support required for patients to retain as much independence as possible by ensuring they gain access to practical support and activities to improve their daily lives and help reduce the devastating effects of loneliness and isolation that many unwell – and often older – people in Sunderland face .  The team explore a multitude of ways to help those in need such as linking them to community activities and services, gaining access to benefit checks to ensure they claim their full entitlements, friendship support and much more.

Often, for those who are living with a combination of health issues, all they need is for someone to be there for them, and to show them they care…

The Living Well Links team is part of the All Together Better programme, led by Sunderland City Council and Sunderland Clinical Commissioning Group (CCG), as part of a national project to pilot new, more effective ways of delivering care.

Tracy Collins, deputy director at Age UK Sunderland, said: “The Living Well Links team has only been in the community for a matter of weeks and already, it is making a positive difference to the lives of people coping with some of the most complex and often debilitating conditions imaginable.

“Often, for those who are living with a combination of health issues, all they need is for someone to be there for them, and to show them they care.  The Living Well Links team has been set up to offer that human touch – practical support that can help people who are managing their health conditions to regain their independence and access to community services so that they can live a comfortable, connected and fulfilled life, working in partnership with health professionals who can take care of their medical needs, and social workers who support their social  needs.”

The All Together Better initiative – which came about following a joint-bid to NHS England from Sunderland City Council and Sunderland CCG – will see a number of changes made, with health and social care teams based together and working in partnership to improve the support to patients who are most in need of joined up care. Sunderland is one of 27 places nationally to be chosen to lead the pilot, which will shape care across the UK in the future.

Councillor Paul Watson, leader of Sunderland City Council, said that this joined up way of working would make a great difference to the lives of people who most need it.

He said: “Working in partnership with the CCG not only makes good financial sense, more importantly, it ensures that care is delivered in a way that takes into account both the health and social needs of the person.  When brought together with Age UK Sunderland’s Living Well Links team, which adds a new dimension to the care we can collectively offer, the result is a holistic model that offers support to treat some of the city’s most poorly people with care and compassion.”

The project is seeing better integration of care to support the most poorly and frail people in the city, as well as improving the process of hospital discharge, which – if not managed effectively – can see people returning to hospital with health complaints that could be better supported at home.  It will also explore how the care of GPs can be better connected to that of other health and social care workers.

NAME, ROLE from WHERE, said: “Bringing together care – both medical and social – is something that can only improve the experience of those who are most in need of intensive care that absolutely meets their needs.

“Through this programme we are genuinely transforming the way we deliver care in Sunderland, and the early signs are that this is working – that we are enabling people to lead the life they want to by helping them to more effectively manage their condition.  To be able to support people to stay in their home – the most comforting and relaxed environment for anyone – is great for the wellbeing and happiness of that person, so this really is a life-changing way of caring for our most vulnerable.”

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