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New team to help frail patients and those with complex needs

Frail elderly patients and those with complex needs living in Dartford, Gravesham, Swanley and Swale are set to benefit from getting more health and care services in their own homes thanks to new multi-disciplinary team (MDT) coordinators.

The coordinators will be managed by us, and we’ll be working in partnership with each area’s local NHS clinical commissioning groups (CCGs).

The coordinators will liaise with GP practices and other partner organisations to identify frail patients, or those with complex needs. They will also ensure multi-disciplinary teams are working effectively for these patients providing them with health and social care services in their own homes.

And this is really important as it is much better for people to receive some services and treatment at home where it is a less stressful and more familiar environment for them.

This helps keep people in their usual place of residence for as long as possible and avoid hospital admissions or transfers to care homes unless it is absolutely necessary.

The coordinators will also work closely with other primary care services such as social services, mental health services, palliative care teams, Virgin Care community services and voluntary services.

In addition, they will help Integrated Discharge Teams at local hospitals to ensure their patients who are frail or have complex needs get the help and support they require when it is time for them to return home.

The team is managed by Zena Evans who has a clinical background in district nursing and until recently, worked for the Sheppey Community Nursing Team.

Zena said: “It is important that all of us that provide care for patients encourage them to share with us what matters most to them to help make their lives better.”

The MDT Coordinators include Charriss Thorne, Janine Pinder and Jenni Mathew, who are based at Livingstone Community Hospital, and Rachel Rogers – the co-ordinator for Swale.  Zena also works across Dartford, Gravesham, Swanley and Swale. The team has already been out and about visiting GP practices and will over time, become familiar faces with the practice teams.

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