South West London CCG Annual Report and Accounts 2020/21

Merton and Wandsworth Supporting patients with complex needs in their own home During the pandemic, keeping vulnerable patients safe at home was more important than ever and could only be achieved by health and care services working closely together. Over the past year, we continued to develop integrated health and care support for the most vulnerable individuals in Merton and Wandsworth by: • Supporting patients at risk of unplanned hospital admission Each GP practice (in Merton and Wandsworth) moved to meeting community health and social care colleagues virtually, to focus on how to support patients at most risk of hospital admission and keep them at home. We extended the Living Well service with Age UK which offers intensive one-to- one support for older people with complex needs, and we proactively identified those in need of additional support. • Reducing isolation and maintaining independence Merton and Wandsworth Voluntary Services established a Community Response Hub in each borough to help isolated households and those at risk from Covid-19, helping with shopping and basic supplies, telephone befriending, access to prescription and medication, advice and practical support to stay active and independent at home. • Enhancing rapid response services Rapid response teams help support people in their own home or care home. To strengthen the service, GPs and social reablement teams worked even more closely with the service provided by Central London Community Health (CLCH), our community service provider. This enabled patients to have access to up to 24-hour care in their home. • Enabling patients to leave hospital and go home sooner In March 2020, at the start of the pandemic, health and social care teams across Merton and Wandsworth set up discharge hubs to enable people to go home sooner from hospital. Discharge processes were simplified, and detailed care assessments were undertaken in the patients home rather than in hospital. From January 2021, health and care professionals in Merton and Wandsworth worked together to identify patients who would benefit from leaving hospital sooner than was usual if they had the right support in place. To enable this to happen, GPs, hospital consultants from St George’s Hospital, community health teams and CCG managers met every day in a “virtual ward round” to discuss patients who could move out of hospital safely into the care of community health and care teams. These patients were transferred home with a care package, which was assessed once they were home. The team looked at patients with and without Covid-19, for example targeting Annual Report and Accounts 2020/21 | 47