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 InputGP Visit

Referral 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 r m e d i a t e C a r e

P a ti e n t J o u r n e y Te a m

G P S u r g 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 r o n s

C a r e A g e n c i e s

V o l u n t a r y O r g a n i s a ti 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 T e a m

Case Studies

• 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.

Video

Co-ordinated Care case Study – Mr Young

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

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 reassuring

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