Sunderland’s innovative All Together Better programme is enabling some of the poorliest people in the city to be cared for at home, rather than in hospital.

Sometimes people just need a little more help than normal in the interim, perhaps if they have an infection or have fallen. The partnership brings together health and social care professionals as well as other local support organisations to help make sure they are looked after at home.

Pensioner John Talbot was recently discharged from hospital and is back where he wants to be – at home. Where once John would have had to stay in hospital, now the care is delivered to him through All Together Better’s Recovery at Home service.

We’re a unique service; we don’t just provide nursing and medical support, we provide emotional care – trying to get people back to their previous independent state…

“It’s nice to be home, and I’m 80 per cent, feeling good,” said John, who, as well as having the full support of a range of carers from the Recovery at Home service, is visited regularly by his sister Judith Duell.

John had been poorly with an infection and had been discharged with the short-term support his sister Judith and Christina Robinson of Age UK Sunderland’s hospital discharge team.

It was Christina who called John’s GP when she suspected he wasn’t well. “We initially came to help John with a referral from Sunderland Royal Hospital to assist with domestic and shopping support, but when I arrived, John was displaying symptoms of being very confused so I phoned the GP and said I didn’t think John was managing his medication,” she explained.

John’s GP contacted the Recovery at Home service who initially sent nurses Tarnya Sillet and Claire Thompson to assess him. The service is committed to a rapid response and John was seen within an hour.

Tarnya explained: “We came in and assessed and examined John and ruled out any infections. We then provided a holistic assessment and made sure he could manage at home. We referred to social services for emergency assessment for a care package and also talked to John’s GP about a medication review.”

After the assessment and reviews were complete, the appropriate care was despatched from the Recovery at Home central hub were a whole range of specialist services sit together including nurses, doctors, social workers; pharmacists and reablement staff sit.

The team could quickly respond to the nurses’ assessment and a both a medicines review and social care assessment were arranged for the next day.

And this community care is exactly the care that John is now receiving, thanks to the All Together Better programme. Instead of being in hospital, he has 24-hour on-call support at home – which is where he’d much rather be.

If needed, Recovery at Home has two community-bed units, one of which is the Intermediate Care Assessment and Rehabilitation (ICAR) unit.

Jane Bowhill, Sister at the unit, explains: “We’re a unique service; we don’t just provide nursing and medical support, we provide emotional care – trying to get people back to their previous independent state.

“Some patients need a lot of emotional support and coaching. Confidence building is important to a lot of the patients, especially if they’ve had a fall and aren’t sure if they’ll be able to manage in their home environment.”

Once someone is discharged from a unit, the team ensures the correct support is in place before the patient returns home, working closely with a GP.

“The GP role is key as we know the patient and we can work with the rest of our community team to prevent problems and crises occurring,” said John’s GP, Dr Taylor.