Care Coordination Team

Our team provides a thorough review of the health and social needs of patients with long-term conditions or frailty. Helping them in accessing services available in South East Essex.

Who the service is for

• Adults aged 18 and over.
• Adults living with frailty or have long-term conditions.
• Living in your own home.
• Vulnerable adults at risk of admission to hospital.
• Patients registered with a GP in South East Essex (including temporary residents) or unregistered patients living within the locality.

Our team will help you access the services necessary for you to stay independent and safe at home. We will review your needs in the comfort of your home, offering referrals, advice, and support. We will also help you create a personal care plan. Our team will work closely with your GP to make sure all your needs, discussed during the assessment, are addressed.

Our aim is also to help you, your family and carers to understand what services are available to you. We 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 tell us when we visit.

What we 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 care plan relevant to your identified needs.
A Care Coordinator will offer you advice and assistance in getting the right support for you, your family and carers. Our service has an internal Pharmacy Team who will review your medications and consult with your GP if there are any concerns.
We have Community Integration Team who can support with social interaction, benefit maximisation, etc. 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

Anyone can refer to us, including the patient themselves. 

Please call 01702 538241 or email epunft.seecarecoordination@nhs.net to talk through the referral.