According to the NHS, the scheme in Wirral is reducing A&E attendances and unplanned hospital admissions for people with frailty and long-term conditions, while also cutting GP appointments by 15 per cent.
Currently, 1,000 people are being supported to remain well in their own homes.
David Hammond, deputy chief strategy officer at Wirral Community Health and Care NHS Foundation Trust, said: “Integrating teams to provide care for patients makes a real difference.
“By working as one team, we’re able to spot issues early, provide personalised support, prevent crises, and help people stay well and independent at home.
“This is helping to reduce unnecessary hospital stays and provide continuity for those with the most complex needs.
“By supporting patients in their own homes, we’re not just responding to illness – we’re preventing it, improving quality of life, and making our local health system more sustainable.”
The programme, which began as a pilot in January 2024, was developed with Moreton and Meols Primary Care Network (PCN).
It has now been extended across four of Wirral’s six PCN areas.
The remaining two are expected to join by the end of 2025.
According to the NHS, integrated care teams, bringing together NHS community services, PCN staff, adult social care, and voluntary partners, deliver personalised care tailored to individual needs.
Referrals typically come from GPs or community teams.
This is followed by home visits to develop an individual care and support plan.
Professor Rowan Pritchard Jones, medical director at NHS Cheshire and Merseyside, said: “Wirral’s proactive care programme is bringing together the teams who support people with frailty and chronic disease to provide increasingly personalised and holistic care.
“This work also embodies the NHS 10-Year Plan’s vision of shifting care from hospital to the community and moving from sickness to prevention.”