Care Connection Teams are a community based multi-disciplinary team that cares for patients aged 18 and over who have been identified by their GP as needing case management as part of their care based on their physical, mental or social needs. The team will conduct home visits in order to undertake a holistic assessment of the patient and their specific requirements and care needs. There are 8 CCT teams covering Hillingdon patients.
The CCT team includes Guided Care Matrons and Care Coordinators or Nurses in addition to Well-Being Assistants and Mental Health Nurses. The team works closely with the GPs within their teams in addition to other community services such as Social Services, District Nursing and Rapid Response.
The main focus for the CCTs is to –
- Reduce unnecessary hospital admissions and A&E attendances
- Provide an integrated level of care based on individual patient need
- Improve the quality of life for the patients within the caseload
- Support and educate patients to manage their conditions and own care
- Provide care and support within patient homes
Patients are referred into the service through being identified within their Hillingdon registered practice. The eligibility criteria will include patients aged 18-55 with have 3 or more long-term conditions whilst patients aged over 55 are eligible with 1 or more long-term conditions.