A pioneering initiative is transforming outcomes for patients in Barrow and Dalton by dramatically reducing hospital readmissions and Emergency Department (ED) visits, whilst delivering a much better quality of care and experience to those who need it most.
The Integrated Wellness Model of Care uses an electronic dashboard to proactively identify people at higher risk of deterioration and readmission, enabling early intervention before health crises occur.
Since its launch in 2025, 151 patients have received active case management through the Integrated Wellness Service led by University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT), with 100% seen within four weeks of hospital discharge.
The results have exceeded expectations and readmission rates have fallen dramatically, with only 5.5% of patients known to the service readmitted within four weeks and 11% within eight weeks - compared to 2023 data suggesting rates would have been 50% and 75% respectively. ED attendances have reduced by 37.8% and hospital bed days by 51.7%.
Beyond the statistical improvements, patients have reported significant enhancements to their quality of life, particularly in self-care, usual activities and reductions in anxiety and depression.
The Integrated Wellness Model of Care has been developed collaboratively in partnership with Lancashire and South Cumbria Integrated Care Board, Westmorland and Furness Council and the voluntary, community and social enterprise sector. It focuses on promoting independence at home, avoiding admission to hospital and putting the individual at the heart of everything it does.
This new approach to healthcare is designed to provide support for people living with complex, long-term health conditions and is provided by UHMBT’s Integrated Wellness Service based at Fairfield Lane in Barrow.
Patients have said: “You created light during a very dark time,” and: “You really listened to me, and you helped me.” Others said: “I don’t feel scared anymore” and: “Thanks for sorting it all out!”
One patient said: “Absolutely nothing has been too much trouble. Anything we have ever worried about has been highlighted and dealt with promptly by our case manager and all the services within the wellness service.”
Another patient summed the service up: “The support I have received has been wonderful. I can't express how grateful I am.”
Built on intensive early intervention, the Integrated Wellness Model of Care supports people at higher risk of deterioration or readmission to hospital, ensuring they are seen within four weeks of discharge from Furness General Hospital (FGH) after three or more emergency admissions in 12 months or a long stay in hospital.
The service brings together a team of health professionals, including a clinical lead, advanced clinical practitioners, nurse case managers, pharmacists, pharmacy technicians, a care navigator, and healthcare assistants. The team works closely with other community services (including specialist services, community therapy, ICC’s, district nurses, and virtual wards), hospital services, adult social care, and local voluntary organisations to provide comprehensive and collaborative support for individuals.
Shaunna Nicholson, Team Lead for the Integrated Wellness Service at FGH, said: “This is a brand-new service for Barrow, designed to fill a 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.”
Jane Scattergood (pictured), Chief Nurse at NHS Lancashire and South Cumbria Integrated Care Board, said: “The Integrated Wellness Service in Barrow is a fantastic example of the power of partnership working in action, with a shared focus of creating a better quality of life for our local communities. Keeping safe and well at home has a wider reach than just the NHS, and this integrated model ensures all aspects of an individual’s circumstances are being considered and addressed.”
Nikkie Phipps, Assistant Director for Care Services at Westmorland and Furness Council, said: “The Integrated Wellness Model of Care shows how much can be achieved when health, adult social care, and community partners work together. Supporting residents to live well at home, reducing hospital admissions and improving quality of life are all shared priorities. We are very proud to be part of such innovative services making a difference to residents’ lives.”
Patients using the service typically have several long-term conditions such as heart failure, diabetes, respiratory conditions, or other serious health issues. Many are frail or have experienced recurrent falls. They are assessed in their own home by a case manager who provides a full holistic assessment. They then will receive a medication review carried out by the pharmacy team. The team also handles care planning and coordination, medical reviews and monitoring, specialist referrals, and social integration support through community groups.
Shaunna said: “Patients tell us they like our service because they feel the service is personal and their case manager is a point of contact who they can call for advice. We help them to learn about their conditions, ways to improve their wellbeing and how they can recognise when their health is deteriorating so they can seek help sooner.”
One Barrow couple shared how the service changed their lives. The husband, who had five ED attendances and four emergency admissions in six months, received a full assessment and ongoing support from the wellness service team.
His wife said: “Before this service, we felt like we were on our own. Now, we have regular visits from the same nurse who knows us and understands his needs. It’s given us peace of mind. We know who to call if something changes which makes all the difference.” Through coordinated care, the patient avoided further admissions and reported feeling safer, more confident and better supported at home.
Nakia Merchant, a Nurse Case Manager within the service, said: “We see patients in their own homes, which makes a huge difference.
“Our initial assessment is very in-depth, covering all aspects of their health and social needs. Over time, as we build trust, patients share more with us, and we can pick up issues that might otherwise be missed.
“The pharmacy team visits quickly after our assessment and can help people who have any issues with their prescriptions. One family told me they love that it’s the same nurse visiting each time. It feels personal and builds confidence.”
Nearly 48% of patients supported by the service are from the most deprived areas, and the highest number of admissions are among those aged 70 to 79 years and 85 plus years.
The service works with Age UK to help patients access financial support. Since March, Age UK South Cumbria has accepted 18 new referrals via multi-disciplinary team (MDT) meetings and enhanced support for 11 existing clients. In the first six months, Age UK identified more than £64,000 in annual benefits and £11,550 in backdated payments, significantly improving patients’ quality of life.
One patient was referred to Age UK through the MDT and received a full benefits review, carer support and home adaptations. The patient was awarded £110.40 per week Attendance Allowance plus £772.80 backdated payments and has not been readmitted since. This patient now has a personal alarm, access to transport schemes and support for their partner through Furness Carers.
Shaunna added: “The teamworking is amazing because we have so 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. It is a privilege to work with so many skilled professionals, teams and organisations. Patients are seen as individuals with their own needs and a story. It is a true passion of mine to provide joined up personalised care for our patients. I am so proud of what we have achieved in such a short time!”
Kim Crabtree, Divisional Head of Nursing for Community, Cancer, Diagnostics and End of Life Care at UHMBT, added: “The Integrated Wellness Model is a fantastic example of how working together across disciplines and sectors can make a real difference to people’s lives. Our colleagues are empowered to deliver truly person-centred care. The results speak for themselves.”
The Integrated Wellness Service is permanent and funded by UHMBT, with plans to expand, if successful. Recruitment is ongoing to meet growing demand and UHMBT aims to further increase caseload capacity and refine the model.
Kim added: “Our Trust Strategy puts patients first and we are fully committed to ensuring that patients and colleagues alike benefit from the innovative approach of our Integrated Wellness Model of Care.”
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Photo captions:
Kim Crabtree, Divisional Head of Nursing for Community, Cancer, Diagnostics and End of Life Care at UHMBT
Shaunna Nicholson, Team Lead for the Integrated Wellness Service at Furness General Hospital, with Nakia Merchant, a Case Manager with the Integrated Wellness Service in Barrow
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