Our small team of clinical staff aim to help people avoid hospital by providing a variety of both clinical and social input. This constitutes part of our broader practice nursing team, within which new roles have been developed to meet patient need.
The team use the year of care approach (care planning) to manage long term conditions, an approach that is used by the Complex Care Team for management of housebound patients with two or more long term conditions.
Our frailty and complex care nurse practitioner Karen clinically leads the team and is able to carry out a comprehensive geriatric assessment looking at all aspects of clinical and social care, create a personalised care plan and encourage wellness and independence with the person who feels they are not coping with their independence as well as they used to . She can support patients through their difficult time being a point of contact for the patient, their family and clinical staff. With her clinical background as Older Person Nurse Specialist and working for a long period in the hospital with Older Person Services Karen can provide the patient with a better understanding of health and try to avoid admissions to hospital.
Julie Bray & Jayne White
Primary Care Navigators
Our Primary Care Navigators Julie and Jayne are trained to support the practice and clinical staff with their knowledge of social prescribing. They began their career at Oxford Terrace & Rawling Road Medical Group as receptionists and health care assistants. They are available to advise and assist patients and carers with any issues of social need that is affecting their health. Having the clinical knowledge enables them to identify any concerns which if necessary they would then bring to discussion with the Complex Care Team facilitated by a weekly multidisciplinary team discussion. This specialised role enabled more time to be spent with a patient directing and supporting them through their stressful and difficult moments of life whilst coping with illness or health issues. The purpose of the PCN is to increase the aim of wellness, independence and social inclusion.
Our Complex Care Team Administrator Elizabeth provides us with an easy access single point of contact for patients, Care Homes, Emergency Services and external organisations. Enabling the patient, carers and staff to access our service safely and ensures that we can support them when they require our assistance. Case finding is one of her roles and will bring those concerns to our multidisciplinary team at weekly meetings
The whole team work together at the Rawling Road site. The multidisciplinary team meeting is held on a Friday each week to ensure that any patients we feel may require more input from a different member of our team have that easy access. This also enables us also to engage support over the weekend should a patient need it. We use this meeting time to discuss new referrals and any issues which need attention.
We accept referrals from anyone who may have concerns that a person may be becoming frail, less independent, or relying much more on family support. We also provide assistance for patients who are finding they have to have increased GP support or attend hospital A&E more often. We are not an urgent response team and so it is always better to inform the team if concerns need to be addressed more timely. We are able also to case find, and are very happy to discuss and support the GP, other health care members and carers with their concerns of a patient.
If you require further information please contact Complex Care Team Direct on 0191 477 3422.
Nurse Practitioner & Frailty Nurse