NNHIP: Strengthening Neighbourhood Care in HMR 
NNHIP enhances HMR’s neighbourhood model by providing the infrastructure needed to manage frailty more effectively. We have moved from a reactive model to a proactive, data-driven system that connects partners across the borough. We will build on HMR’s strong neighbourhood foundations, focuses on enhancing the way teams work together across the system to support residents living with moderate and severe frailty. The multiagency emphasis ensures that those at greatest risk—such as high intensity service users, care home residents, people at end of life, those with cardiovascular conditions and individuals experiencing frequent falls—are jointly identified, reviewed and supported through neighbourhood teams. 

• The Focus: Supporting residents with moderate to severe frailty, particularly those at the end of life or at risk of frequent falls. We will also focus on their carers to ensure they can live their life without challenges faced caring for someone with frailty. 

• The Integration: Bringing together primary, community, and urgent care services into a single, cohesive Multi-Agency Team. 

• The Innovation: Scaling the use of Tech-Enabled Care (TEC) and standardising Comprehensive Geriatric Assessments. 

• The Goal: Reducing avoidable hospital admissions and providing faster, community-based crisis support and better care coordination for our cohort population.