Louise Rycroft Care-Coordinator

Priorslegh Medical CentreMcIlvride Medical Practice

The Schoolhouse Surgery, Disley Bollington Medical Centre

33,000 patients

Our elderly population is 50% higher than the

National average

“Vulnerable patients who may need extra support”

Patient Criteria

• To support and coordinate care for patients with complex medical conditions who are discharged from hospital.

• Making contact with outside agencies on behalf of the patient should it be required.

• To improving the quality and efficiency of the current discharge processes.

• To make better uses of resources in Primary Care and the community.

• To develop better partnerships working across the peer group and across agencies.

• To alleviate any worries or concerns a vulnerable patient may have once home aiding their recovery.

Our Aims

• Discharges from GP surgery

• Clinicians who have visited patients and feel extra support is needed for the patient or their family/carer

• Friends and family of patients expressing concern

The care coordinator will then make contact with the patient within 3 days.

Referral Process

Care Coordination Input

GP VisitReferral to Community Matron District Nurse

Visit Ambulance Booking

Find out appointment details

Referral to Macmillan Nurses

Organise Respite Help organising carers

Providing telephone numbers Referral to Social Services

Help with medication

Carer’s Support Signposting to voluntary services

The wider team…

I n t e rm e d i a t e C a re

Pa t i e n t J o u rn e y Te a m

G P S u rg e r i e s

M a c m i l l a n N u r s e s

D i s t r i c t N u r s e s

C o m m u n i t y P h y s i o / O T

C o m m u n i t y M a t ro n s

C a re A g e n c i e s

Vo l u n t a r y O rg a n i s a t i o n s

S o c i a l S e r v i c e s – S t o c k p o r t ,

M a c c l e s fi e l d , W i l m s l o w , D e r b y s h i r e a n d

H o s p i t a l Te a m

CaseStudie

s

• Mr S is a carer for his wife who has Alzheimer's Disease.

• He is managing her care by himself and is happy to continue to do this.

• He was concerned about what to do/who to contact in an emergency.

• We have provided him with a list of local agencies who he can contact should he need to.

• We make contact once a week.

• Mr H lives alone and has memory problems.

• He has no family locally – his Power of Attorney is his niece who lives in Wales.

• He has been referred to the Memory Clinic for a formal diagnosis.

• We liaised between the Memory Clinic and his niece to organise this appointment.

• We have also arranged transport for him to attend an x-ray appointment.

• We called him regularly throughout the morning to remind him who his driver will be, when he will be picked up and the reason for the appointment.

Co-ordinated Care case Study – Mr Young

https://www.youtube.com/watch?v=6gF9_SKGm4M

Video

Feedback

received

Feedback

I’m so lucky to

have this in my area

That’s a brilliant idea and could be really helpful. Thank you!

This is so reassurin

g

I think you are both

stars!

You are a god send and I am more than impressed

with the service

This is so helpful it will be great for

me and my husband

You’ve been ever so helpful,

thank you

It’s very nice that someone

is thinking of me

Everything has been sorted thank you so much for your help. What a

fantastic service

Community Matron Team

“I think the biggest benefit is that communication has improved

regarding individual patients, and that everyone involved is kept in

the loop.”

Stephanie Hambleton &Anne Hitchen

District Nurses

“I feel the service has significantly improved the

patient journey.

Working Together is a valuable source of

information for us.”

Janine BennettDistrict Nurse Team Leader

General Practice

“I have found the service most valuable for improving

communication and freeing up time within General Practice. Louise & Hollie take on a lot of

work that would otherwise default to General Practice.”

Rachel Dougan Triage Nurse

General Practice“The working together model has proven itself to be an invaluable aid to assist the

coordination of care post discharge in an all too often disjointed system.  It has also

successfully piloted a shared project across a peer group with the associated benefits

that brings.  

The fact that within a very short space of time, the Working Together project has

become an accepted and valuable part of the post discharge care, is testament to both

the concept and more importantly the staff delivering it.”

Dr David Ward GP