The diagram below provides an overview of the process to ensure patients can access the package of care they need as quickly as possible. However, please note that the process flows will change and adapt as the ECP programme develops.
The stages are:
- Sollis used the top 5% of population at risk of emergency hospitalisation who are known to Community Services, on the PACT AUA register, had greater than 2 inpatient admissions and their Resource Utilisation Band (RUB) is high or very high. This list was then sent to the practice to check and verify.
- Within the first two weeks the Health & Social Care Coordinators (H&SCC) at your practice will collate the final ECP patient list and share this with St George’s Community.
- The GPs will then invite each of these patients to a PACT consultation to develop a shared care plan. The GP Federation have developed a new EMIS care plan template and this is the template that should be used. All PACT ECP patients should have a care plan using the new template by October 2016.
- After the PACT consultation the H&SCC refers the patient to CAHS through the Access and Coordination hub:
Tel: 020 8812 5000
If you need to contact CAHS regarding your ECP500 register please e-mail: stgh-tr.ECP500Wandsworth@nhs.net
- CAHS will review the care plan (via EMIS) and reply to the referrer within 1 week to:
- Confirm receipt of referral.
- Agree date of MDT meeting to discuss the patient and care plan. Please note that the MDT will happen at some point between July and December 2016 – there will still need to be ongoing communication between Primary Care and Community Services and updates made to the care plan to ensure care is delivered during this time. If you haven’t heard back within 1 week, it is recommended that you chase the referral.
- CAHS will visit the patient and assess their needs.
- CAHS will host the MDT meetings. Both the GP and the H&SCC are required to attend in person, if possible, or use teleconference facilities. The next review date for the care plan is agreed. The care plan and package is updated on EMIS.
- Care is delivered by the various organisations such as CAHS, Mental Health, Voluntary Sector and Social Services. After each contact the care plan is updated on EMIS.