South West London CCG Annual Report and Accounts 2020/21

vulnerable patients are supported through the Community Response Team with food and medication delivery, welfare checks and coordination of statutory and non-statutory support, as appropriate. Patients are also supported after discharge from hospital, including those with chronic diseases and long Covid. The service also actively manages patients who are at risk of deterioration, where they have significant anxiety because of this. A remote monitoring system, which supports clinical management and escalation of patients, is being piloted. Phase 1 of the service has been designed for: o Adults 18 years and over. o Patients with acute Covid or Covid related symptoms who have been discharged from hospital to the Community Pulse Oximetry @Home Service. These patients are at significantly higher risk of deterioration and this enhanced monitoring and treatment gives confidence to discharging clinicians and patients that they will be safely ‘cared for’ virtually. Covid-19 positive patients in learning disability and elderly residential care homes. Going forward, as part of phase 2, the service will support: o Non Covid-19 patients with chronic long-term conditions such as COPD, heart failure, uncontrolled diabetes, frequent callers or frequent attenders who are at risk of hospital admission and require multidisciplinary primary and community support for a short period. o Frail patients who require short intensive support with social and wellbeing interventions to prevent unnecessary hospital admissions. Following the implementation of Sutton Covid Virtual Ward, weekly MDT meetings have evolved to virtual ward rounds which are held three times per week with input from hospital respiratory consultants. Between February 2021 and March 2021, total of 108 patients were admitted to the virtual ward, including the pulse oximetry service. Support for care homes For over five years the Sutton Health and Care system has built a strong partnership to provide oversight and support to care homes within Sutton. The system is overseen by the Sutton Health and Care Executive, which includes Sutton Council, NHS South West London, Sutton Health & Care Alliance (health and care providers) Our partnership has given us a strong foundation to quickly respond and provide effective, joined up support to care homes before and during the Covid-19 pandemic Annual Report and Accounts 2020/21 | 57