This practice's 'complex care team' provides a multi-agency approach to supporting patients with acute needs, that saved £148,000 in one year.
Other practice activities have included walks and exercise classes, on-site mental health services, expert patient programmes, a toe-nail cutting service and a pulmonary rehabilitation course.
They have also brought acute services closer to home, with consultant clinics in rheumatology, older age medicine and paediatrics, and specialist nursing in audiology, mental health and heart failure.
Upton Surgery senior partner Dr Susanna Everitt said: 'Our strategy has been to integrate with our colleagues in community services, secondary care and very much with patients, to get everyone working towards the same ends.'
Dr Everitt said practice development manager Philippa White had helped develop the scope of the team, with her nursing and PCT background.
'Philippa has a much broader vision than most practice managers, always seeking to look at the wider implications of what we are doing and ensuring that we are a part of the community.'
The complex care team evolved from the allocation of a health visitor to care for the practice's elderly population.
Dr Everitt said: 'We have developed this into a situation where our team leader goes in to hospital to find our patient and looks to arrange an early discharge, pulling all of the resources together so that we can keep people at home.'
PMS funding allowed the practice to develop the service and it became a practice-based commissioning pilot evaluated by local universities and found to be making major savings on excess bed days and hospital admissions. The initiative is rolling out across Worcestershire.
Ms White said: 'The team makes a huge difference to people's lives. It's really rewarding to get them on their feet again, taking medications and able to look after themselves.'
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