South West London CCG Annual Report and Accounts 2020/21

Supporting shielded and vulnerable patients We have worked to ensure that the joined-up ways of working that have been developed during this time across primary and community care are embedded into the way we work going forwards. • Community response teams Primary Care Network Clinical Directors have worked with partners to develop four Covid-19 community response teams (CRTs) wrapped around primary care networks. These multi-disciplinary teams (MDTs) include community nurses, care home support teams, learning disability (LD) nurses, Age UK Sutton, community mental health, social care, pharmacists and GPs with management support provided by the primary care team. The MDTs support vulnerable people identified as shielded, care home residents and people at the end of their lives. In addition, a closer relationship has developed between LD nurses and the Joint Primary Care Clinical Director leads for LD. Their co-ordinated approach to supporting LD residential care homes has enabled targeted support to be optimised and accessible at the point of need. This approach has transformed the existing care home support team into a seven day a week service and supported the night nursing community team to develop closer working with general practice and wider health and care teams. CRT meetings are held formally on a weekly basis with regular contact and communication between teams throughout the week. This work was already in development as part of our Sutton Health and Care programme. However, as a result of our Covid-19 response, we have seen the rapid implementation of a delivery model that has provided the platform for us to achieve integrated multi-disciplinary teams. GP practices also worked to support patients who had to shielding. These patients were contacted to discuss what shielding means, any changes to their ongoing care and treatment, to confirm what arrangements they have in place for receiving medications and to ensure they are aware of the government support offer. Social prescribing is an integral part of the PCN’s MDT response to supporting patients identified by GPs with complex medical and social needs; those at risk of loneliness, isolation and requiring support with food delivery whilst self-isolating. Sutton’s Social Prescribing Service has engaged with over 500 people since 2019. The community response team’s work has been further enhanced by the development of the Sutton Covid Virtual Ward which was launched on 2 February 2021. • Covid-19 Virtual Ward The Covid Virtual Ward has been developed, with the aim of prioritising patient safety and care and delivering community wraparound services to support prevention of unnecessary hospital admission. The most 56 | NHS South West London Clinical Commissioning Group