Haringey Coordination and Prevention Service (HCAPS) (previously Haringey Integrated Locality Team)

Haringey Multi-Agency Care and Coordination Team

Main Address

Haringey Multi-Agency Care and Coordination Team:
Managing health, wellbeing and preventing crises through innovative partnership working
 

Who are we?
The Multi Agency Care & Coordination (MACC) Team is a proactive and preventative care service for adults living with frailty or complex long term health care needs.  We work in partnership with Haringey GP practices to identify those who may benefit from our support.

We are an integrated team of professionals from multiple disciplines and agencies. The team includes:

• Multi-disciplinary team (MDT) tele-conference
• Social workers
• Mental health workers 
• Occupational therapists
• Physiotherapists
•  Navigators 
• Pharmacists
• Community matrons
• A general practitioner
The role of the team is to support patients to maintain health, well-being, independence and self-management of their health conditions. We are the Haringey Hub for Integrated Working.

What do we offer?
As an anticipatory care service we aim to keep people well, work towards their goals and reduce avoidable hospital attendances or crises.

Referrals will be triaged by a senior clinician and if accepted may be proposed to MDT teleconference, and or receive a holistic assessment (comprehensive geriatric assessment where appropriate).
We can provide tailored interventions to support the client’s medical, functional, mental health and social care needs. Adopting a patient centred approach, we set goals with our clients and create personalised care and crisis plans. 

The team can coordinate care needs and will work in partnership with professionals already involved in a client’s care to provide wraparound multi-disciplinary support. We are well placed to link our clients with other services and support they need to make a positive difference to their health and wellbeing.


Referral

You can refer people with multiple long term conditions impacting on daily life, and require a multi-disciplinary approach to support to maintain health, well-being and independence.

Self- Referral
 
You can contact the team to make a self- referral over the phone. If you are new to the The Haringey Coordination and Prevention Service (HCAPS), we will ask you GP to send us some information on your long term health conditions.
If you have worked with the team previously we will review your situation and offer advice on the next steps.
 
GP Referral
 
GPs can refer into the service using a variety of ways to make the process easier for each individual GPs preference. From GPs we accept CRAT form referral (ticking The Haringey Coordination and Prevention Service (HCAPS) (previously known as Haringey Integrated Locality Team) / Under ICTT), a completed The Haringey Coordination and Prevention Service (HCAPS) referral document or an email with a brief statement of need along with an EMIS summary.
 
Professional or Supporting Role Referral
 
Health & Social Care Professionals, Volunteers and other workers can refer into the team using the Community Adults Referral Form (CRAT) or the Haringey Integrated Referral Form Document.
 
Proactive Referral
 
You may be contacted by us by a letter through the post and a follow up phone call. Your details will have been gathered from data relating to Emergency department and London Ambulance contact in the best interest in of improving your care.
 
We will offer to review your health and social care situation and may offer you support in working with you to improve your health and wellbeing. You can accept or decline this offer.
 
Integrated working
 
If you would like the team to work with you  in a development capacity to share our learning about integrated learning, improve links with your Haringey Service or any other development opportunities please do not hesitate to contact the team managers Toby Kent or Laura Marmion to discuss further or call on 0203 0742958.
 
Choosing the Right Treatment
 
We look forward to working with our new clients and new colleagues before. We would ask everyone to review the following information on choosing the right treatment to ensure you and your clients get the best care at the correct time by choosing the NHS service that can best treat your symptoms.
 
To access the evening & weekend GP appointments
call (0330 053 9499) during the following times:
6:30pm-8:30pm Monday to Friday
8:00am-8:00pm – Saturday and Sunday

Appointments

You can refer people with multiple long term conditions impacting on daily life or people that have frailty with rising risk, and require a multi-disciplinary approach to support to maintain health, well-being and independence.
An example of such are those who:
• Recently returned home from an unplanned admission to hospital
• Are at risk of falls or repeat falls
• Live with dementia which is having an impact on daily function and/or those who are carers themselves
• Have medication compliance or polypharmacy issues
• Are not engaging with services and at risk of frailty deteriorating


Service Criteria
• Adults living in borough of Haringey registered with a Haringey GP.
• People living with moderate or severe frailty with rising risk; Electronic Frailty Index (eFI) ?0.25 or Rockwood Clinical Frailty Score of 5 or above. Please see Clinical frailty scale (nice.org.uk)
• People living with multiple and/or complex long-term health conditions (including dementia) who would benefit from MDT input.
• People who require coordination of their care, whether already known to multiple services or not.
• People who have frequent unplanned hospital admissions and are at future risk of this continuing.
• People who are carers themselves where the care is at risk of breaking down.

Exclusion Criteria
• Where the sole need can be met by a single service (e.g., Package of care only or for major adaptation = Social services; acute mental health crisis = BEH; rehab therapy input = ICTT ).
• Immediate admission avoidance cases or those who need to be seen within 12-24 hour (Rapid Response).


Please send this form and any supporting documentation/information (e.g., EMIS/recent clinical letters) to: whh-tr.MACCT@nhs.net
Contact: 020 3074 2958 to discuss referrals or leave messages for the team.

Though the MACC Team are not an acute service. We aim to triage our referrals within 24 hours (excluding weekends and bank holidays). Following triage, your client will be contacted and assessed dependant on clinician prioritisation (We operate on a 6 week maximum waiting time).

If you feel that a person is at immediate risk of hospital admission or imminent care breakdown, please refer to the Rapid Response service via their registered G.P or directly on 0207 288 3670

Self- Referral
If you have worked with the team previously you can contact the team to make a self- referral over the phone, we will review your situation and offer advice on the next steps. If you are new to The Multi Agency Care & Coordination (MACC) Team, we will ask your GP to make the referral and to send us some information on your long term health conditions.

GP Referral

GPs can refer into the service using a variety of ways to make the process easier for each individual GPs preference. From GPs we accept ), a completed MACC referral form or an email with a brief statement of need along with an EMIS summary.
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