Vulnerable Adults Service
The Norwich Vulnerable Adult (VA) model is a tiered, step up, step down integrated model of care for adults with complex needs and severe multiple disadvantages. The patients supported are often homeless, living in temporary accommodation or accommodation which may be at risk. Individuals are supported in the most appropriate tier, based on their acuity and complexity. The Inclusion Health Hub is for individuals experiencing acute chaos, extreme complexity and multiple co-morbidities. It is intended that individuals will only spend a short time (ideally less than 6 months) being supported by the Inclusion Health Hub before being ‘stepped down’ to the less intensive service.
The service commenced in April 2020 at the midst of a global pandemic, and despite the impact and challenges this posed the service continued to grow. Key recruitment 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 new service successfully transitioned from the old service model provider to Norwich Practices Ltd (NPL) as the new service provider
The core team of a service lead, clinical
lead, ICC and support workers adopted a collaborative working approach which
created processes to follow by holding weekly Multi- Disciplinary Team (MDT)
meetings with partners and stakeholders. Communication networks with Inclusion
Health Practices (IHPs) were established and regular meetings and discussions
implemented to improve patient care. A
partnership approach was adopted to ensure that contributions from
professionals within the IHPs and linking with their own ICCs was established
to strive to continually improve the service and patient experience.
The service was subject to the Health
Overview Scrutiny Committee in October to ensure it was deemed as safe and
beneficial. The outcome from the HOSC
was wholly supportive, and the aim being that services of this type will be
rolled out across the county, which is fantastic.
The service offers a holistic approach to
patients care, and we now look to use the input from the integrated care
coordinator (ICC) to discuss 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 through each tier of
the model for patients and addresses the wider determinants of health. In addition to this, it also supports new
working relationships across sectors with an MDT approach that really does put
the patients at the centre and ensures that complex vulnerable patients are
kept safe and are supported.
You will find more information here.