Complex care teams across Devon will;

    • Provide a single point of co-ordination for referrers.
    • Deliver a responsive and timely service for the individual.
    • Ensure a multi-disciplinary assessment and response to the needs of the individual and their carer.
    • Provide a case management approach for people with long term conditions and / or complex needs as appropriate
    • Work across organisational boundaries, with adults and their carers to promote independence and choice either in their own homes or as close to home as possible.
    • Work in partnership with the Voluntary and Community Sector to facilitate access to community based services to support individual’s well-being - reducing dependence on statutory interventions.
    • Utilise a range of ‘case finding tools’ to proactively identify people who may be at risk of loss of independence or unnecessary hospital admission.  A case finding paper.has been adopted by the Department of Health and will be recognised nationally as a good practice guide for supporting case finding activities.
    • Working with an enabling approach that supports self determination and independence – for example through the use of direct payments, self care, and self directed support

The real benefits of the complex care teams will be

    • Emergency bed days reduced by 5%
    • Reliance on secondary care services reduced
    • Timely assessment and care / treatment plans delivered
    • Reduced delayed hospital discharges
    • Reduced avoidable admissions to long term care
    • Provision of care in a primary, community or home environment increased.
    • Individuals with long term conditions receiving high quality care personalised to meet their individual requirements.
    • Improved support to carers to enable them to remain in a caring role.
    • An effective, systematic approach to the care and support of people with a long term condition embedded into local health and social care communities.

We will be able to provide a personal and proactive face-to-face service to vulnerable people with complex care needs. We aim to provide high quality and tailor-made care and services in people’s homes and in the local community. This will help us to reduce the number of hospital admissions and the number of avoidable admissions to long term care.

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