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Care Co-Ordination Team

Aims and objectives of service

The aim of the Care Co-ordination Team is to ensure that people's needs are correctly assessed and appropriately met when they move from acute care to community care. It aims to reduce the number of admissions and re-admissions to hospitals and increase the proportion of care delivered in the community.

Urgent Care Co-ordinators organise the appropriate community care for all Nottingham City registered patients supported by the CCT to avoid admission into acute care or those who have been identified as needing a ‘supported discharge’ from hospital.

Service description (including STOC - Supported Transfer of Care)

The service is delivered by senior clinicians, with support from In Reach Workers and Urgent Care Co-ordinators. They work closely with hospital-based teams to co-ordinate the safe and timely transfer of the care of patients into the community.

The team proactively identifies patients in Nottingham University Hospitals (NUH) settings whose care needs could be more appropriately met in the community. It assesses whether patients could be supported in the community and organises the appropriate discharge and their ongoing support needs.

Members of the team identify, assess and prescribe any equipment the patients may need in the community such as specialist beds or pressure-relieving mattresses and cushions. They advise and support patients and families in discussing care options in the community.

A named Case Co-ordinator acts as the point of contact between agencies and develops close working relationships with partner organisations (NUH, Nottingham City Council, Nottinghamshire County Council and County Health Partnerships) to ensure the effective transfer of care.

Urgent Care Co-ordination function (Nottingham City only): Urgent Care Co-ordinators act as the interface between the integrated Care Co-ordination Team and community service providers to receive referral information and co-ordinate the appropriate response based on clinical need with the most appropriate services. They can be contacted via a single referral point and it is the responsibility of the co-ordinator to liaise with all relevant statutory and voluntary sector services, including the local authority, to arrange the necessary support.

The co-ordinator liaises with all community services involved in the patient's on going care regarding their progress in hospital and provides discharge information to all community teams.

Days/hours of operation

The service is available between 8am and 10pm every day of the year.

Population covered

The service is available to anyone aged 18 or over who is registered with one of the following Clinical Commissioning Groups (CCGs) under the care of Nottingham University Hospitals NHS Trust:

In addition, the Urgent Care Co-ordinators provide a service to patients aged 18 and over, registered with a NHS Nottingham City Clinical Commissioning Group GP practice and identified as medically stable and requiring supported discharge from a NUH HCOP or QMC base ward.

The Care Co-ordination Team: Choose to Admit service accepts referrals from the Queen's Medical Centre Emergency Department; Wards B3, B57, B50 and Lynn Jarrett Unit for patients aged 18 and over who are registered with a GP practice within Nottingham City, Nottingham North and East, Nottingham West and Rushcliffe CCG areas and who are medically stable and meet the criteria of the receiving community service.

How to contact the teams

Current referral is via healthcare professional only. If you are not sure which area you sit in, consult your internal documentation otherwise use the numbers below:

At a Glance:

Direct

tel:

See below

Accessing the Service

You can be referred by:

Professional

Service availability

City

County