The South Cumbria Integrated Wellness Service identified 835 people who had been admitted to hospital 3 or more times in a year – or had a very long stay. These patients made up less than 3% of the population but accounted for nearly a third of all hospital bed days.

A small team including GPs, case managers, pharmacists, occupational therapists and patient navigators worked with these patients in the community. Support included help with medicines, care planning, mental health services, financial advice and a virtual ward to avoid unnecessary admissions.

For the first 267 patients seen:

• emergency admissions fell by 62%
• hospital bed days fell by 66%
• accident and emergency attendances fell by 42%
• patients also reported improvements in their quality of life.

Find out more: The South Cumbria Integrated Wellness Service (PDF, 232KB)