How commvita holds a single, shared picture of a person with complex needs — an Integrated Neighbourhood Team working one risk-tiered caseload, a shared cross-org record, mobile field visits with NEWS2, frailty (CFS 1–9) and virtual-ward step-up, and a concierge that removes admin friction — so multi-disciplinary care at home stays joined-up, not fragmented across systems.
Complex care fails at the seams — between GP, community nursing, social care, mental health, pharmacy and the acute front door. commvita closes those gaps with one team, one record and one layer that runs the work, all built person-first to the data-lineage standard.
A neighbourhood MDT — GP, community nurse, social worker, mental-health, pharmacist, paramedic — works a single shared caseload with risk tiers and a complexity score, MDT reviews with action tracking, and a task board. Nobody works a private list.
A shared MDT record distinct from the GP FHIR record: every timeline entry carries an MDT action menu — raise an MDT task, referral, care-plan change or escalation — so the record drives the work as well as describing it.
A Next-Best-Step layer over transport, appointments, community support and referrals — with delegated access & consent (grantor → delegate, access level, expiry, revoke) so a carer or family member can help without seeing the whole record.
The Integrated Neighbourhood Team is commvita’s answer to the NHS England neighbourhood-health mandate: a multi-disciplinary team holding one shared caseload for a ~30–50k population, prioritised by risk tier and complexity so effort goes where need is greatest.
GP, community_nurse, social_worker, mental_health, pharmacist and paramedic sit in one team — the Team Overview roster — so complex care is delivered by a group instead of handed between silos.
Every person on the caseload carries a risk tier (high / medium / low) and a complexity score, so the MDT can triage — the frail, multimorbid and socially complex rise to the top of the list.
Reviews record decisions with action tracking, and a task board (kanban by status) turns the plan into owned, visible work rather than minutes filed and forgotten.
| Person | Risk tier | Complexity | Lead | MDT review |
|---|---|---|---|---|
| Margaret Whitfield · 78y | High | 84 /100 | Community nurse | Due today |
| Ade Nwosu · 71y | High | 77 /100 | GP | Due in 2 days |
| Joan Petrie · 83y | Medium | 58 /100 | Social worker | Booked 14 Jul |
| Derek Cole · 66y | Medium | 49 /100 | Pharmacist | Booked 16 Jul |
| Priya Shah · 74y | Low | 31 /100 | Mental health | Not due |
The team reaches the person where they live. The Community Nursing Portal is a mobile-first field app (My Day / Patient / Intervene / Caseload / Sync) built for door-to-door working — including when there’s no signal.
My Day shows the day’s visits with status advance (scheduled → en route → on scene → completed), navigate and call links, and a lone-worker check-in for safety.
Intervene captures vital signs (HR / BP / RR / SpO₂ / Temp / AVPU / pain 0–10) and auto-calculates the NEWS2 score with a RAG band, plus wound care and medication forms — so deterioration is scored at the bedside, not back at base.
Records complete without connectivity and queue via IndexedDB, syncing when back online (the Sync tab) — essential for rural and low-signal community work.
Complex community care is, very often, frailty care. The Frailty Programme assesses with the Rockwood Clinical Frailty Scale (CFS 1–9) and a multi-domain complexity score, then offers a Virtual Frailty Ward step-up — acute-level monitoring at home instead of admission.
A visual Rockwood CFS 1–9 assessment combines with mobility, cognition, nutrition, function and social domains into a Frailty Complexity Score — and for CFS ≥5 it links to SDOH and social prescribing.
NEWS2 sparklines track trajectory; a rising score triggers a step-up into the Virtual Ward acute-at-home command centre — live bed board, remote observations, MDT review — keeping the person at home where it is safe to do so.
A 6-modality intervention tracker connects to social prescribing, falls management (predict / prevent / detect / respond, connected sensors), continuous RPM and Discharge to Assess — so frailty is managed across settings instead of in a single clinic.
| Capability | Module | Route | Standard | Status |
|---|---|---|---|---|
| Neighbourhood MDT · risk-tiered caseload | INT Hub | /int · API /int/ | NHS England neighbourhood health · NICE NG56 | ● Live |
| Shared cross-org MDT record · action menus | Neighbourhood Health Record | /nhr · API /nhr/ | PRSB Core Information Standard · FHIR R4 | ● Live |
| Cross-setting whole-person view (12 tabs) | Whole Person Record | /patients/:id/whole-person | openEHR · Care Act 2014 · GP Connect | ● Live |
| Frailty · CFS 1–9 · complexity | Frailty Programme | /frailty-programme · API /frailty/ | BGS frailty · NHS LTP · NICE NG56 | ● Live |
| Acute-at-home step-up · NEWS2 obs | Virtual Ward | /virtual-ward · API /virtual-ward/ | NHSE acute-at-home · NEWS2 (RCP 2017) | ● Live |
| Social prescribing directory | SP Directory | /social-prescribing-directory · API /social-prescribing-dir/ | PCN social prescribing · SDOH linkage | ● Live |
| Mobile field visits · NEWS2 · offline | Community Nursing Portal | /community-nursing | NMC 2018 · NEWS2 (RCP 2017) · NICE SC1 | ◍ Demonstrated |
| Person orchestration · delegated access | Concierge | /concierge | person-first data-lineage · GDPR Art.15 | ◍ Demonstrated |
| Discharge to Assess · P1/P2/P3 · community capacity | commvita Flow — Community Capacity | /flow | NHSE Best Practice Discharge Framework 2023 | ◍ Demonstrated |
| Falls · predict / prevent / detect / respond | Falls Management | /falls-risk-assessment | NICE CG161 · RCP NAIF · PSIRF | ◍ Demonstrated |
| Continuous RPM · Waiting Well | Continuous RPM · Waiting Well Hub | /continuous-rpm · /waiting-well | NICE ESF · NHSE Elective Recovery | ◍ Demonstrated |
| Personalised care plan | Personalised Care Plan | /patients/:id/care-plan | personalised care & support planning | ◍ Demonstrated |