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 seams with one team, one record and one orchestration layer, 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, not just describes 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, not 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, not 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 |