Teams
Complex Care at Home
Gloucestershire
The Complex Care at Home Team provide personalised support and care to adults who are losing their independence and resilience due to multiple/complex needs. This support will include care co-ordination, clinical expertise, health coaching and information and advice to help people manage their conditions, enabling them to access on-going low level support in the community.
Complex care at home
The teams operate in Cheltenham, Gloucester and the Forest of Dean.
Referral Criteria
- Over 18 and registered with a GP within Gloucester, Cheltenham or the Forest of Dean
- Consented to referral (cognition considered)
- Rockwood score of 4-7
- 2 or more Long term conditions (including frailty)
- Becoming reliant on unplanned or Emergency care
- At risk of unplanned admission
- Has had unplanned admission in the last 6 months
- Has health and wellbeing goals/ambitions
- Would benefit from MDT approach to personalised care and support planning
Exclusions
- People referred solely for therapy support of needs (Refer to ICT)
- People without 2 long term conditions
- People referred solely for nutritional support
- Complex mental health conditions
- Active substance misuse
- Referral solely for memory assessment or mental health assessment – Refer to Memory Assessment Service (MAS)
- People with no physical health conditions
- End of Life Care
Service aims
- Maximise independence and build resilience
- Proactively identify and assess frailty
- Provide ‘personalised care’
- Case management – join up care and support
- Support carers
- Help access services and support designed around the individual
- Help with social isolation and wellbeing
- Acknowledge and ensure equality and equity
- Public engagement and involvement
- Recognise and support people with dementia and confusion and their carers
- Share information with other teams and work with hospitals, local council services and the voluntary sector.
Contact us
Email: ComplexCareAtHome@ghc.nhs.uk
Call: 0300 421 1389
