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The Norwich VA model is an integrated model of care for adults with complex needs and severe multiple disadvantages aiming to address health inequalities. The patients supported are often homeless, living in temporary accommodation, hostels or where their accommodation is at risk. The Inclusion Health Hub is for individuals experiencing acute chaos, extreme complexity, and multiple comorbidities. It is intended that individuals will spend a short time (ideally less than 6 months) being supported by the Inclusion Health Hub. Users are then integrated into primary care provision within the Norwich Primary Care Network (PCN) to one of the 12 Inclusion Health Practices to ensure a supported transition and to plan for ongoing needs. 

Inclusion health practices can refer patients registered with them to this service where they meet the identified needs for inclusion health hub. This enables these patients to benefit from the support of this specialist service.
Intensive collaborative working between the team has enabled the service to become robust and resilient and able to create a structured focus to strive to achieve the requirements of the new model and improve both the health outcomes for patients and address inequalities.

The core team of a service lead, clinical lead, integrated care coordinator (ICC), GPs, nurses and support workers adopted a collaborative working approach, holding weekly multi-disciplinary team (MDT) meetings with partners and stakeholders to provide holistic joined up care and support for patients.

We have had a positive media report from Norfolk Healthwatch this year about our service.

The Vulnerable Adult service ICC supports and coordinates potential onward referrals to other non-clinical services and interventions that will give patients greater support networks within the community.

This social prescribing approach enhances the ease of the transition to an inclusion health practice and addresses the wider determinants of health. The model ensures all patients have equitable access to health services within the PCN.

You will find more information here.