Hospital readmission rate slashed in new scheme
UHMBTA scheme designed to reduce the amount of times patients return to hospital has seen a drop in readmission rates, an NHS trust has said.
Patients in Barrow and Dalton, Cumbria, who suffer long-term conditions such as heart failure and diabetes, have been taking part in the Integrated Wellness Model of Care initiative.
Led by University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT), it sees hospitals work with social care and community services to identify those at higher risk of readmission and put measures in place to prevent it.
Since its launch in 2025, 151 patients were flagged as being at risk, with only 11% going back to hospital within eight weeks - down from 75% in 2023.
Shaunna Nicholson, the service's team lead at the Furness General Hospital, said the service filled the gap between hospital care and community services.
"We work with people who've had recurring admissions and provide early intervention and support to help them manage their health at home," she explained.
'Build trust'
UHMBT said the patients were often frail or had repeatedly fallen.
The scheme works by assessing them in their own home and coordinating care including medication reviews, specialist referrals and support through community groups.
Ms Nicholson said it meant if a patient was deteriorating it could be spotted sooner.
Nakia Merchant, a nurse case manager within the service, said seeing patients in their own home made "a huge difference".
"Our initial assessment is very in depth, covering all aspects of their health and social needs," she said.
"Over time, as we build trust, patients share more with us and we can pick up issues that might otherwise be missed."
Age UK is also a partner in the scheme and can help patients access benefits advice and financial support for home adaptations.
Ms Nicholson said different teams working together meant there were many skills to draw on.
"If one person doesn't know the answer, someone else will and it means we can really get it right for our patients," she said.
The initiative is funded by UHMBT which said it planned to expand it to increase the number of people it can support.
