Patient Details

Date of birth
Europe/London
Gender
Address
Patient has given consent for referral

Referral will not be accepted if consent not obtained

Referrer Details

Address
Date
Europe/London

Criteria for referral

The person is able and motivated to work with the service to develop an individual care plan that  helps them feel more confident to manage their healthcare conditions, and aims to reduce avoidable admissions to hospital
Age > 18 years AND
2 or more long term health conditions (see over for more details) AND
Have had 1 or more A&E attendances and / or unplanned hospital admissions in the previous 3 month period 

 

Required

Criteria Included Excluded
Resident / registered population of Tameside & Glossop  The resident / registered population of Tameside & Glossop health and social care economy  
2 or more long term conditions Including (but not restricted to):
Frailty
Respiratory problems (including COPD, Bronchitis)
Diabetes
Neurological disorders
Cancer
Heart Disease (including Atrial Fibrillation, heart failure)
Chronic Kidney or liver disease
Chronic bowel disorders
Chronic neurodegenerative conditions, such as Parkinson’s		 Primary diagnosis of cancer
Acute Oncology
Specialist neurodegenerative conditions
Primary mental health conditions
Have had 1 or more A&E attendances and / or unplanned hospital admissions in the previous 3 month period Those patients who are actively accessing secondary care unplanned services  Paediatrics
Drugs / Alcohol related
Pregnancy
Adults All patients aged 18 years + Paediatrics / all patients aged 17 years or less

The Extensive Care Team will use their clinical discretion when triaging all referrals received by the service.