The CCT has a wide skill set and many years of professional experience; covering mental health, substance misuse andpsychosocial issues.
Every patient referred to the CCT goes through an initial assessment. This involves being seen by two members of the team, usually at the patient’s home. Once the assessment is complete, the patient will be coordinated to the team member(s) most appropriate to help improve their situation in order to explore their health and well-being needs. A Clinical Pharmacist is also involved in the assessment process, particularly useful for those patients on multiple medications (poly-pharmacy).
The service also uses risk stratication to proactively identify patients and prevent hospital admissions. Service criteria:
- Vulnerable adults over 18yrs
- Over 65-year-olds
- At risk of unplanned admissions
- Not already on alternative schemes such as Pro-Active Care, Care Home schemes
- Frequent attenders to A&E, GP surgeries and emergency services
Once a patient is referred to our multidisciplinary Collaborative Care Team, they work across organisational boundaries to ensure services are brought together to support the patients’ needs through care planning and Multi-Disciplinary Teams(MDT). Part of the role of the CCT is to network with the voluntary sector and signpost patients to appropriate agencies. The CCT will also aim to offer educational input for patients on how best to use services, and to offer clinical input when appropriate.