A NEW care co-ordination service has been launched in Southend offering early support and a co-ordination of care for people with complex needs. The Complex Care Coordination Service is led by a team from the South Essex Partnership University NHS Foundation Trust (SEPT) and aims to identify and support patients to maintain personal independence, delay disease progression and improve overall outcomes.
The service has been commissioned by NHS Southend Clinical Commissioning Group (CCG) and will see health and social care staff from a number of agencies working side-by-side including local GP practices, social care and housing, community physical and mental health and substance misuse. The service aims to:
1. Support GP practices to improve the health and social wellbeing of those living with frailty and or complex needs from 55 years and over
2. Maintain optimum levels of independence and recovery through the provision of effective and coordinated health and social care services
3. Prevent the individuals’ needs escalating and avoid increasing demand on health and social care services, both pre and post hospital admission
4. Provide a complex care coordinator as a dedicated and consistent point of contact
5. Provide timely access to support and reconnection to local communities through dedicated complex care navigators
6. Work with complex care patients to help them understand what services may be available to them
Sharon Houlden, Director of Adult Services and Housing, Southend-on-Sea Borough Council, said: “I am really excited about the introduction of the complex care service in Southend. Social workers and their health colleagues will work side-by-side. This will help them have a strong understanding of their local community and engage wholly with residents to maximise independence and inclusion and reduce marginalization.”
Southend’s NHS and social care services are being arranged around four localities (West, West Central, East Central and East) and the new service is initially being launched within East Central before being rolled-out in the remaining three localities. Each locality will have a named Complex Care Coordinator and a named Complex Care Navigator.
Dr Josè Garcia Lobera, Chair of NHS Southend CCGsaid: “We have identified a cohort of patients across the borough whose needs we consider to be amongst the most complex and who already access a range of different health and social care services, and may also have repeated hospital admissions. By delivering all their services together through a multidisciplinary team of health and social care workers we can place the patient at the centre of these services and better support them within their own home, delivering much better outcomes for them.”
The service is expected to be co-ordinated and integrated with other services which support and deliver care to individuals with complex care needs, their carers and families including:
- Community Geriatrician
- Community Falls Team
- Community mental health services
- Voluntary Services and Community Groups
