Continuing Care Team

Patient advisor team

Call handling role
Booking appointments
Directing patients to appropriate pathways
Able to transfer patients to patient navigators for further advice and support

Patient group
- Generally well patients with new problems
- Emergencies
- Urgent care
- Ongoing care transferred to continuous care team
- Over flow from continuous care team
- Morning ward round and support for community beds
Located at current minor injuries unit Lewes Victoria
staffed 8-8 5 days a week maybe 7 days in the future
Twice daily meeting 8am and 1pm

Nurse practitioner
- Extended role of current minor injuries nursing staff
- Able to see acute problems in generally well people
Paramedic
- Visiting role for acute illness in complex patients unable to leave home to support continuous care teams
- Visiting role for acute illness in generally well patients unable to leave home eg, back pain
Physio
- Direct access to physiotherapy for acute musculoskeletal problems
- Provide ongoing role for patients with primarily musculoskeletal problems

Patient group
- Complex patients
  - Routine follow up with proactive management
  - Daily appointments for urgent problems
- Case management for complex patients with less current needs
  - Practice based case management by patient navigator
  - Home based patient management by visiting case manager
- Responsibility for 5000 patients with all levels of complexity to enable moving between pathways
- The most complex patients supported by specialist case management
Located at Hub and Ringmer branch surgery
Staffed 8.30-5pm
Meet daily at 12.30pm

Staff
- Patient navigator
- GP
  - Small team of GP’s to provide 5 day availability
  - Named team for every patient
- GP trainee
  - Supported training by team of GPs
  - One GP in the continuing care team is a trainer
- Telephone recognition software directs phone calls to case manager for complex patients
- GP
- Junior pharmacist + reception prescription clerk
- 1 session per week for nursing home ward round

Patient group
- Complex patients requiring specialist case management
  - Case manager appropriate to patients needs
Located at Health Hub
Meet twice weekly
Staff
- GP to chair meetings
- Community nurse
- Palliative nurse specialist
- Community psychiatric nurse
- Social worker
- Occupational therapy/community physiotherapy
- Patient navigator
- House bound case manager/Frailty HCA
  - Less complex house bound needing proactive care

Patient group
- Less complex long term conditions
Located at Health hub rotating to Ringmer branch surgery
‘One stop shop’ aimed at seeing patients for all their routine medication and chronic disease reviews at one appointment
Routine blood testing and blood pressure monitoring
Majority of prescription requests dealt with in this team
Staff
- Senior pharmacist
  - Provides oversight and medicines use reviews
  - Authorises repeat prescribing
  - Authorises simple acute prescribing
- Prescribing clerk
  - Processing prescription requests