Community Integrated Teams
All Together Better is not only bringing together care for the most vulnerable people in the city, but it is uniting the teams who deliver that support, to ensure that people only need to tell their story once.
Five multi-disciplinary Community Integrated Teams (CITs) are now in place to provide an effective, high quality and coordinated response to the most vulnerable people with the most complex needs, keeping them out of hospital.
Based in key localities in the city – Bunny Hill, Downhill; Hendon; Houghton; Grindon and Washington – the teams are made up of district nurses, community matrons; general practitioners, practice nurses, social care professionals, living well link workers and carers support workers. By working from one shared base, they are able to avoid duplication of work, which can not only be costly to the NHS, but can also be very frustrating for the patient, who would have to tell their story to each health and care professional providing them with support.
The CITs are together creating holistic health care plans with patients and carers, that are absolutely tailored to the needs of the person, and these are supported by their own GP, who will lead clinical decision-making to ensure that the medical, social and emotional needs of their patient are taken into account.
All Together Better brings together health and social care teams, as well as the voluntary sector, to create a brand new way of delivering care to some of the most debilitated people in Sunderland.
Sunderland Clinical Commissioning Group; Sunderland City Council; Age UK Sunderland; Sunderland Carers Centre; local Hospital Trusts who provide services like nursing care in the city; pharmacies and therapies; as well as all local GPs, are working in partnership to create All Together Better, which provides round-the-clock support for those who need it most.