Integrated Care

Each Practice within the PCN, has their own assigned Care Coordinator who can work closely with staff to identify and support patients.

Care Coordinators will work with patients with complex or long term health conditions.  These patients may need assistance to coordinate their care e.g.; if they have multiple appointments and are struggling to manage them or to find transport to attend.

Your Care Coordinator will carry out a personalised holistic assessment of the patient and can assist with identifying care needs.  The patient may need a care needs assessment from social services or they may be struggling to manage around the house.  They may have concerns around their memory or be having problems with incontinence.  The care coordinator can assist in integrating health and social care and ensure the right care is provided at the right time.

Your Care Coordinator can also work with unpaid carers and family members of patients with Long Term Conditions (LTC) or complex needs.  Carers are often not aware of the support that is available to them and benefit greatly from the Care Coordinator service.

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Each Practice within the PCN, has their own Social Prescriber who will work with patients who have social problems and issues.  These can include debt, benefits advice, housing, social isolation, domestic abuse, employment or any other social issues which may be affecting their quality of life.

Social prescribing link workers connect people to community-based support, including activities and services that meet practical, social, and emotional needs that affect their health and wellbeing. This includes connecting people to statutory services for example housing, financial and welfare advice.

Social prescribing works particularly well for people with low level mental health needs, who feel lonely or isolated, with long term conditions and complex social needs.

Social prescribing link workers work collaboratively across the health and care system, targeting populations with greatest need and risk of health inequalities. They collaborate with partners to identify gaps in provision and support community offers to be accessible and sustainable.

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