This is to improve care for vulnerable patients who are at high risk of multiple admissions to hospital.
We will identify patients who are at high risk of unplanned admissions to hospital.
Such patients will have a package of care with full involvement of the patient and carer.
Components of the care will include
- You will have a ‘named GP’ (this will be your usual GP) as the accountable GP who takes overall responsibility of coordinating your care.
- In addition to surgery telephone number, there is a dedicated telephone number for patients on the plan, accident and emergency clinicians, ambulance staff, and care homes. This is to support decisions relating to admissions and transfer to hospital.
- For urgent queries you can telephone us using the dedicated telephone line. Your urgent queries will be answered the same day.
- You will have a ‘personalised care plan‘. The care aspects will be shared with you and the document given to you. This document will have details of your medical conditions, results of laboratory tests, medications you are taking and allergy. Where relevant, your wishes on care, like end of life care and allowing natural death to occur will be recorded in the notes.
You need to keep this document with you at all times and carry with you when you access other services like accident and emergencies and out of hours service. - Your GP, as the accountable GP, will have the overall responsibility of your care supported by a named care coordinator.
The care coordinator is the person, other than the GP, who sees you regularly. This can be district nurses, community matron or manager of the care home.
The care co-ordinator will be responsible for ensuring that the agreed care plan is being delivered, that the patient or carer is informed of any changes made to the plan and keeping in contact with the patients or their carer at agreed intervals. - If you are admitted to hospital we will review your care to see if the admission was avoidable and also ensure you will have timely and coordinated care following discharge from the hospital.
- We will review your care every month.