Translate
The proactive care team offers comprehensive healthcare and support services tailored to people aged 18 and older who are living with frailty, multiple chronic conditions or complex needs.
Their goal is to empower these individuals to maintain their independence and overall wellbeing within their preferred living environment, whether that is in their own home or a community setting.
The team provide a personalised approach to care that aligns with an individual's unique needs and preferences, while also striving to address health inequalities and improve outcomes for the Enfield population.
They work closely with our community matrons and other healthcare providers to deliver co-ordinated care through multidisciplinary team meetings, helping to prevent unnecessary hospital admissions.
The team is made up of the following experts:
-
Peer workers who offer support and guidance based on their own experiences.
-
Care navigators who help patients access services and resources.
-
A registered mental health nurse who provides specialised mental health support.
-
Community matrons or case finders who identify patients who may benefit from our services.
-
Social workers, a therapist, a palliative specialist nurse, and Age UK who provide non-clinical support.
Patients can be referred to the proactive care team through various channels:
-
Multi-disciplinary team meetings: healthcare professionals can discuss patient cases and determine if referral is appropriate.
-
Risk stratification tool: an electronic method used to identify patients at risk of frailty or complex needs.
-
Direct referrals: primary care providers, secondary care specialists, and other stakeholders can refer patients directly.
To make a referral, please complete the form below and email it to northmid.ecsadultsinglepointofaccess@nhs.net. In the section asking which service you are referring your patient to, please select ‘Enfield community service multi-disciplinary team’.
