Once your referral has been received, it will be reviewed and a decision made about the possible treatment or care. You will then be contacted by the appropriate team with the relevant information.
Referral Criteria
Inclusion Criteria:
- Over 18 years of age
- People residing in their own home, or those in a Kirklees temporary community bed-based setting.
- Two or more complex Long-Term Conditions (multimorbidity): Asthma, Coronary Heart Disease, COPD, Diabetes, Heart Failure, Hypertension and Frailty (moderate/severe).
With:
- Two or more unplanned admissions to hospital due to their long-term condition(s) in the last 12 months
- A&E attendance on 3 or more occasions due to their long-term condition in the last 12 months and/or have been admitted as an emergency for a chronic ambulatory care sensitive condition (ACSC)
- High intensity user of ambulance services – 999/111 (using YAS criteria) where a physical health long term health condition is a contributing factor, and a community review is required (unable to attend GP practice)
- High intensity user of GP services – attended 10 or more consultations within a 6-month period and the referrer believes that the patient requires a holistic assessment of their health needs.
- Patients with progressive moderate to severe frailty requiring intervention or management to prevent hospital admission.
Exclusion Criteria:
- Acute mental health issues
- Alcohol/drug dependency
- Individuals who have had a mechanical fall (covered by the falls service/community rehabilitation/ or UCR teams)
- One LTC (covered by specialist teams i.e. Heart Failure or Respiratory team)
- Solely safeguarding concerns
- Solely End of life or Advance care planning (covered by GP/DN team or The Kirkwood)
- Solely Annual review (covered by the LTC review team)
- Older people’s care home residents (covered by Care Home Support Team).
- Referrers should consider any high-risk patients deemed as ‘urgent’ requiring a 0–2-hour review, are not appropriate for Ageing well triage and should be referred directly to the UCR service initially.
