What we do
The Care Coordination Centre streamline all referrals into Adult Community Services. We are here to help patients, relatives and other professionals ensure they access the right services they need. We triage all contacts made to us, ensuring onward referrals are made as needed but also give health advise and education – we are a large team of professionals from different backgrounds, and we are well placed to support you.
We aim to ensure community services are accessed as required, and to also avoid hospital admission unless clinically indicated – along with supporting patients who are housebound with long term health needs, we also help access a rapid assessment for those who are acutely unwell.
When a patient is admitted to hospital, we are also here to support the planned discharge planning process and work with you to ensure a seamless, safe, and timely discharge home is achieved. To achieve this the Care Coordination In-reach Team visit ward areas, working collaboratively with our colleagues in the acute setting.
Additionally, the Discharge to Assess (D2A) Team, which is part of the Care Coordination Centre, helps manage patients being discharged from the hospital who may require ongoing care, rehabilitation in a bed-based setting, or further assessment for 24-hour nursing care. These services serve as a crucial link between the acute and community environments, facilitating a seamless transition from the hospital to the patient’s home while considering all aspects of their care needs.