Description

Community matron Amanda Whitley introduces the Proactive Care Team (PACT) – a dedicated resource supporting vulnerable, frail adults with enhanced proactive care within the three community partnerships of central Bradford (PCN 4/5/6).

The PACT team is experienced, multi-disciplinary and culturally competent.  It brings together diverse skills including Admiral Nurses for specialist dementia care, advanced care and end-of-life planning and support, physiotherapy, psychological support, speech and language therapy, dietary advice and occupational therapy. It works to enable prevention, recovery and sustainability so people can live well and avoid unnecessary A&E, urgent care admissions and visits to primary care.

The Proactive Care Team (PACT) is supported by Bradford District and Craven NHS Clinical Commissioning Group and delivered by Bradford District Care NHS Foundation Trust in partnership with Bradford Teaching Hospitals NHS Foundation Trust, Dementia UK and City Health Bradford GP Federation.

Find out more about our team in this video:

PACT referral criteria

(Scroll down for Admiral Nursing service referral criteria)

Adults aged 18+ who are living with two or more non-communicable conditions, persistent physical symptoms or frailty, leading to frequent attendances at primary and secondary care services, falling through gaps, poor quality of life and patient dissatisfaction.

Enhanced levels of support will be provided to meet exacerbations of need for a defined period.

In Scope Out of scope
Residents registered with a CP4, 5 & 6 general practitioner Residents not registered with a CP4, 5 & 6 general practitioner
18 years plus with multimorbidity Under 18
Complex social, emotional and psychological needs that impact on health and wellbeing People with uncomplicated needs that could be met through ‘statutory’ teams/services
People whose needs are impacting/likely to impact on avoidable use of primary & secondary care  
People in the last 12 months of their life

Admiral Nursing service referral criteria

The following criteria must be met:

The person with dementia or suspected/carer has consented to the referral and receipt of the service.

The person with dementia and / or family carers are concerned about memory problems or suspected dementia which is causing complexities within the caring relationship.

Where dementia is suspected, dementia screening bloods must have been reviewed with no suspected physiological cause for neurological deterioration. If there are medical conditions or differential diagnosis such as delirium or depression that may be causing neurological deterioration these must be corrected prior to referral being made to the Admiral Nurse.

Exclusions:

The primary need of the person with dementia, carer or family is not related to the dementia (for example a significant mental health problem requiring a different service, or underlying physiological problems which could be causing neurological impairment)

Head injury that is a primary diagnosis to cognitive impairment.

Crisis management requiring response within 120 hours.

How to refer to PACT or the Admiral Nursing service

Please use the E-referral form on SystmOne for the Proactive Care Team.

Further information

For more information about the Proactive Care Team, or to speak to a team member about a referred service user, please contact us on 01274 256131.

The Proactive Care Team

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