Collaborative Care Team
Leading Healthier Lives
Collaborative Care Team
The Collaborative Care Team (CCT) can support you to stay independent and safe at home whilst facing challenges such as physical, mental health, substance misuse, and psychosocial issues.
Our main objective is to prevent hospital admittance and ensure you live a healthy life in your own home.
Eligibility Criteria
We can support patients that meet the following eligibility criteria:
- You feel as though you are a vulnerable adult 18 years+
- You are at risk of unplanned admissions
- You have issues with medication
- You require social care needs
- You require psychosocial care needs
- You have low level OT requirements
- You have issues with benefits
- You are a frequent attender to A&E, GP practices and emergency services
Length of Intervention
Once you have been referred to the Collaborative Care Team via your GP practice, the team will visit you at home and will draw up a personalised care plan with you regarding your needs.
We will then work with organisations to ensure services are brought together to support you including educational advice on how to best use these services and offer clinical advice where appropriate.
How do I refer myself?
You can get referred by your GP at your GP practice if you meet the eligibility criteria.
Frequently Asked Questions
From when we receive the referral from your GP practice, we will be in touch with an initial assessment appointment within 10 working days.
We always visit patients in their homes if appropriate.
If you can’t make your appointment or would like to change it, please give us a call on 01604 970917 to let us know at the earliest convenience.
Yes. You would need to grant us permission to view your full medical records for us to work with you. This is so we can inform your GP/practice on our care plan that we have created with you.
We ensure that we find solutions that are tailored to your needs. Once we have finalised a personalised care plan, we will work with you to find suitable solutions that work for you. If something isn’t working for you, we can re-evaluate.
We also work with other services such as: Mental Health, District Nurses, GPs, Pharmacists, Ambulance Services, and other appropriate clinical teams.
Initially up to 12 weeks, however, we will not discharge you from our service until we feel as though your needs are met.
Case Study
Story
A client, who is 57 years old has history of agoraphobia and severe depression. She lives alone but is unable to leave her flat due to her diagnosis which means she is unable to visit family, friends, attend appointments or do her own grocery shopping.
Goals
The client felt she had no purpose in life, she wanted to be able to control her diagnosis better and feel confident enough to leave her home to do the little things she enjoyed in life. She aspired to feel good about herself again and take control of her life.
Solutions
The CCT team visited the client frequently to build trust and familiarity. They created a Care Plan to support the client, ensuring that she felt supported and not overwhelmed. The CCT team helped the client do short, frequent walks downstairs and slowly helped her build her confidence to go just outside her flat. She was referred to Happy @ Home volunteer service and to CMHT for Mental Health to try to overcome her struggles.
Outcomes
The client was able to leave her flat, even if it’s for a short amount of time and she has formed a friendship with a lady she met at the Happy @ Home volunteer service. Eventually, the client was able to build her confidence to do her own shopping, socialist with friend and improve the quality of life.
Patient Testimonials
