Care Co-ordination Centre for Frailty Patients (Pilot in Stevenage)

About the Service

From 27 June 2022, Hertfordshire Community NHS Trust is providing a Care Coordination Centre for frail residents in Stevenage.

This new service has been developed by Hertfordshire County Council and Hertfordshire Community NHS Trust to provide an integrated triage function and care co-ordination across multiple organisations.

The Care Co-ordination Centre will ensure a person receives the right intervention at the right time, by the right professional.

Patients will be triaged by the East and North Hertfordshire Integrated Care Co-ordination Centre and Multi-organisational Multidisciplinary Team who will agree the most appropriate organisation to undertake an initial visit with the patient.

The visiting organisation will feedback to the Multidisciplinary Team and any additional referrals or input from other organisations will occur.

Updates on interventions or frailty status are monitored and tracked by the East and North Hertfordshire Integrated Care Co-ordination Centre and the referring service will be kept informed of the action(s) taken. The Care Co-ordination Centre will act as a central point of information and co-ordination and will ensure system-wide visibility of people with frailty and their past/current support.

Any patient who is registered with a GP practice in Stevenage and who has been identified as frail or who is recovering from or at risk of falls can be referred. If referrers are not sure which pathway in the community a patient requires, or if a patient requires multiple referrals to multiple services, then a single referral can be sent into the Care Coordination Centre, who will triage and ensure the patient is placed on the correct pathway.

The pilot will run in Stevenage for 3 months and there will be continuous evaluation for the duration of the pilot period and a final evaluation will be completed to include any lessons learned, and changes that are required prior to the wider roll out across the East and North Herts system.

Clinic Locations

The service provides a single point of access for all referrals (community and acute) where a person has been identified as frail or at risk of falling or who may have already fallen.

Contact us

Who is eligible for this Service

Making a referral