Case Management

• Patients in primary care requiring an ’urgent’ response from a Neighbourhood Team (NT).  In this context, ’urgent’ means any patient who is not currently on a NT caseload. Patients currently known to a NT should be referred directly to that team.
• Patients in acute units who need support from a NT on discharge
• Patients in acute units who need transferring to a community hospital bed
• Patients possibly needing admission, but where alternatives may be available:
• Possible medical admissions
• Possible care of the elderly
• Possible community Hospital admissions
• Possible palliative care admissions
• Neighbourhood Team care
• Catheter problems

AtC is prepared to assist in any other situation where the referring clinician feels alternatives to acute admission may exist.

Cases can be referred using the following methods:

• Telephone
• Fax
• Email
• Via the website

As a general guide, AtC would prefer simple requests to arrive via the website / email. This will give the administrative and clinical staff more time to manage complicated cases.

Possible admissions should, whenever possible, be phoned through to AtC to allow a thorough clinician to clinician assessment.

• Whichever route is used, referrals are in most cases managed initially by the administrative assistants. Information from the written referral or caller, if the contact is by phone it is entered on to AtC’s database.

Prior to its launch, Access to Care worked very closely with Adastra, the principal supplier of software to OOH providers to develop bespoke software for use within the service. This has proved very successful and continues to be refined as AtC progresses.

• In simple cases, the referral is passed directly to the intended recipient (e.g. a Neighbourhood Team).
• If the case is more complicated, it is passed to one of the clinical advisors. A telephone call from a clinician may be transferred or, if the referral was originally ’paper based’ the information is passed electronically.
• The clinical advisor will then decide how the case is to be managed. Sometimes they will be assisted by an advanced Practitioner. Having determined the appropriate pathway the clinician will pass the referral to the relevant organisation.
• Further support, if needed is provided by the administrative assistants. Transport requests are a typical example.

Referrals are passed in a variety of ways:

• All urgent referrals are notified by phone with details then being passed electronically.
• Where possible all referrals are transmitted electronically – in many cases this is possible using Adastra as all the Neighbourhood Teams are now able to receive them directly.
• If there is no electronic capability, referrals are faxed