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
- Patients with unmanaged multiple long-term conditions with complex needs
- Patients that are unwell due to their long-term condition (The agreed LTC accepted are Asthma, COPD, Diabetes, Heart Failure, and bronchiectasis)
- 2 or more unplanned admissions to hospital in the last 12 months with a problem related to same diagnosed long-term condition (please refer individuals who have had a 'mechanical fall' to the falls service/community rehabilitation / START team)
- Attended A&E on 3 or more occasions in the last 12 months with a problem relating to physical health for the same diagnosed long-term condition.
- High intensity user of ambulance GP or 111 services where a physical health long term condition is a contributing factor.
- Patients on CNN caseload with an identified unmanaged complex need
- Patients with progressive moderate to severe frailty requiring intervention or management to prevent hospital admission
Please note:
- The service does not accept referrals for acute mental health issues, alcohol/drug dependency
- You will no longer receive an email from us to confirm we have received your referral.
