Care Coordination Service

What Is Care Coordination Service?


This is an NHS service tailored to help patients navigate through health, social and voluntary services. We assess you in the comfort of your own home, providing referrals, advice and support. Our aim is to ensure you have the services you need to allow you to stay independent for as long as possible. We will work with you to create a personal care plan which highlights any areas where you may require support. Our team works closely with your GP to ensure all your needs, which we discuss during the assessment, are met.


Our aim is also to help you, your family and carers to understand what services are available to you. Our staff will refer you to the services and share, as appropriate, your information with the health and social care professionals involved in your care. If you do not wish for this to happen please advise us when we visit.


What Does the Service Do?


The service offers you the opportunity to be holistically assessed by an experienced professional; usually a qualified nurse or a social worker. They will work with you to co-produce a suitable care plan relevant to your identified needs.


A named Care Coordinator will be provided to work with you to agree a support plan which will help you keep well. We can offer advice and assistance in getting the right support for you, your family and carers. Our service works with the Pharmacy Team who will consult with your GP to help with your medication needs.


We also have experienced health care assistants who will provide you with ongoing support throughout your health and social care journey.


We can also refer you to receive a range of services beneficial to you. These could include:

- Benefit entitlements

- Befriending service

- Advocacy services

- Occupational Therapy

- Fire services

- Reputable Services to support you around your home





Who Will Benefit From This Service?


If you are:

- Adults aged 18 and over

- Adults living with frailty or have long-term conditions

- Living in your own home

- Tend to use emergency services frequently

- Vulnerable adults at risk of admission to hospital

- Have consented to treatment

- Patients registered with a GP in South East Essex (including temporary residents) or unregistered patients living within the locality


Unfortunately we cannot support you if you are:

- Living in a care or residential home

- Under the identified age bracket


How Long Can The Service Help Me?


Your health and wellbeing is our primary concern and we will work with you throughout your health and social care journey. We will work to your pace with regards to the level of care you need. The support given will be tailored to the level of your need at any given time. You can make contact to the service at any time if you require extra support because of a change in your medical or social condition.


How Can I Refer To The Service?


The service will accept referrals from your registered GP with your consent. We can also receive referrals from other professionals such as: Social Workers, Community Health Teams, Palliative Nurses, Occupational Health Teams, and voluntary and community services. If you are a patient, friend or relative you can also self-refer to the service for support.


How to contact us?


Our champion is Georgia, send her an email at sccg.carers.southendmedicalcentre@nhs.net