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
  •  

Contact us

Email:  ComplexCareAtHome@ghc.nhs.uk
Call: 0300 421 1389

Locations for this service

Accessibility