Care coordinators play an important role within a Primary Care Network. They proactively identify and support patients, including the frail/elderly and those with long-term conditions. The team provides coordination and navigation of care and support across health and care services for those patients. The care coordinators ensure that patient health and care planning is timely, efficient, and patient-centred.

Care Coordinators invite patients for reviews of their long-term conditions, screenings or vaccinations when they are due. They also book patient appointments with the most suitable clinician when online requests are made. This may not always be a GP, for example, they may book a patient to see First Contact Practitioners (physiotherapists), Physician Associates, Clinical Pharmacists and Social Prescribing Link Workers, amongst others, where this is most appropriate. This helps free up GP time for those patients that need to see a GP.

Care Coordinators also organise and document the monthly meetings in GP surgeries with various health and care professionals, known as Multi-Disciplinary Team meetings (MDTs). These meetings discuss some patients in each practice with more complex health needs. The wide attendance at these meetings helps to ensure that patients can be seen by the most appropriate teams in a timely way.

The aims of our Care Coordinators are:

• To help patients see the right professional for their concern
• To provide quick and effective support to manage patient requests sent online
• To support non-clinical support teams in the GP surgeries to be able to have more time to focus on patients that cannot use online services
• To help clinical and non-clinical teams work together to make sure patient need are met
• To help make sure practices and PCNs can reach as many eligible patients as possible for important things like cancer screening

The role of the diabetes dietitian is to help support you to achieve a healthy diet and lifestyle in the best possible way for you.

We would like all patients who have diabetes or pre diabetes (non-diabetic hyperglycaemia) or post gestational diabetes or polycystic ovary syndrome (PCOS) to visit:

Know Diabetes website  Diabetes in North West London | Know Diabetes to find out more about services and resources available to you.

If you have type 2 diabetes and would like to attend the X-PERT type 2 diabetes programme here is the self referral link to join Type 2 Diabetes – Group Education Learning (jotform.com)

If you have type 2 diabetes you can also click on the following link to find out more about programmes available to you:

If you have pre-diabetes or post gestational diabetes or PCOS or want to lose weight or improve your health & lifestyle you can also click on the following link to find out more about programmes available to you:

Hounslow lifestyle services available for prediabetes, post gestational diabetes, PCOS or want to lose weight or improve health & lifestyle

If you still have a dietitian need you can be referred by your GP to the diabetes dietitian. Appointments with the diabetes dietitian are provided on the telephone or online using Microsoft Teams. There is limited availability for face to face appointments.

If you’ve got new pain in your joint or muscle, your GP Surgery may decide to offer you an appointment with a Musculoskeletal First Contact Practitioner (FCP). As highly trained Physiotherapists, their job is to assess and diagnose your problem and provide a treatment plan. Your FCP will organise any prescriptions, scans, tests or referrals they think you need. They can also provide a fit note if required.

Conditions FCPs can help with include:

• All soft tissue injuries, sprains, strains or sports injuries

• Arthritis – any joint

• Possible problems with muscles, ligaments, tendons or bone, e.g. tennis elbow, carpal tunnel syndrome, ankle sprains

• Spinal pain including lower back pain, mid-back pain and neck pain

• Spinal-related pain in arms or legs, including nerve symptoms, e.g. pins and needles or numbness

• Changes to walking

• Post-orthopaedic surgery

Some patients will not be suitable to see a First Contact Practitioner, this includes:

• Acutely unwell

• Children under 16

• Medical management of rheumatoid conditions

• Women’s health, antenatal and postnatal problems

• House-bound patients

• Medication reviews

• Neurological and respiratory conditions

• Headaches

• Acute mental health crises

• Patients who do not want to see a FCP

Appointments

Your GP surgery may offer you an appointment with the FCP based on your symptoms. You can self-refer to see an FCP by contacting your GP as you usually would for an appointment – please indicate that you would like to see an FCP. If your symptoms are appropriate for an FCP and you do not meet the exclusion criteria, then the team can offer you an assessment with the FCP.

As with all appointments provided by your GP surgery, if you cannot attend your appointment, please notify your GP surgery as soon as possible. This will help to make your appointment available for another patient. If it is a same-day cancellation, it is best to call your practice. Otherwise, you can contact your practice as you normally would.

Mental Health Practitioners are now working as part of most Hounslow GP surgeries to help patients get the support they need. They are healthcare practitioners trained to support patients with their mental health. They support your GP by helping to get patients quicker access to mental health expertise.

If you are referred to a mental health practitioner, they will work with you to understand your needs. After assessing your needs, they will provide treatment advice and support shared decision-making about self-management. If appropriate, they may support you with brief interventions relevant to your needs over a small number of sessions. Where needed, they can make referrals to specialist mental health services.

Mental health practitioners can:

• help you with talking therapies to support a wide range of topics and issues

• provide tools and techniques to help manage symptoms

• support you if you are experiencing the psychological effects of managing long-term conditions, such as diabetes

If you, or someone you know, is struggling with mental health issues, speak to someone at your local GP surgery who can arrange the right kind of support for you.

For more urgent advice and support, West London NHS Trust provides a Support and Advice Line on a 24-hour, 7 days a-week basis which can be accessed via 0800 328 4444. This service is provided by specially trained mental health advisors and healthcare professionals who will be able to offer support and guidance around the next steps for you or the person you are concerned about.

Your appointment

You will be booked to see a mental health practitioner by your GP surgery where appropriate. Your appointment may be face-to-face or via a video or telephone call.

If you cannot attend your appointment, please notify your GP surgery as soon as possible so your appointment can be made available for another patient. If it is a same-day cancellation, it is best to call your practice. Otherwise, you can complete an online form to cancel or reschedule an appointment.

Signposting Self Care to mental health resources

If you would like more support for your mental health please see links below.

Kooth- Home – Kooth

Every Mind Matters- Every Mind Matters – NHS (www.nhs.uk)

Good Thinking- Digital mental health and wellbeing support for Londoners | Good Thinking (good-thinking.uk)

Paramedics are registered healthcare professionals who have a unique role that crosses health and social care, public health, social care and public safety.

The paramedics in your Primary Care Network (PCN) are a home visiting service and support urgent care and assessment for housebound patients. They also carry out Long Term Conditions (LTCs) reviews for permanently housebound patients. They work independently to provide care in a range of situations but always stay in contact with your GP about any care provided.

If you are referred to the paramedic, they will attend on behalf of your GP. Your paramedic will work closely with your GP to manage any follow-up actions from your visit, so you don’t have to—for example, referrals or changes to medication.

Appointments

Your GP will refer you to the paramedic team. Paramedics will visit patients requiring urgent care on the same day. The paramedic will contact you for routine visits to arrange a time to visit you at home. However, as the team needs to respond to the changing wellness of patients and could be impacted by traffic, they may need to make changes at short notice.

As with all appointments provided by your GP surgery, if you cannot attend your appointment, please notify your GP surgery as soon as possible. This will help to make your appointment available for another patient. If it is a same-day cancellation, it is best to call your practice. Otherwise, you can contact your practice as you normally would.

Physician Associates are medically trained, generalist healthcare professionals who work with your GP to provide medical care. Physician associates work under the supervision of a GP, but can work independently with appropriate support.

Your PCN Physician Associates work as part of your GP surgery team to review, examine and propose specific management and treatment plans for patients. A Physician Associate can support you with short-term and long-term medical issues. They can provide most of the care and support you require, including referrals.

There are a small number of things the team cannot do which includes signing sick notes, prescribing medications or requesting ionising radiation investigations such as X-rays. However, they will work closely with your GP where these are required so this is managed for you.

Appointments

You will be booked to see a Physician Associate by your GP surgery team where appropriate. This may be in response to a request for help with a medical concern or as part of your care for any Long Term Conditions.

As with all appointments provided by your GP surgery, if you cannot attend your appointment, please notify your GP surgery as soon as possible. This will help to make your appointment available for another patient. If it is a same-day cancellation, it is best to call your practice. Otherwise, you can contact your practice as you normally would.

Social prescribing is a personalised approach to healthcare that looks at all the possible needs of individuals from a non-clinical point of view. It recognises that people’s wellbeing is determined by a range of social, economic and environmental factors (e.g. housing, financial, employment, isolation). It is by addressing these concerns that individuals become empowered and attain greater control over their lives and therefor their health and wellbeing.

Social prescribing links people to services and groups in their local community in accordance with their needs.

Social prescribing link workers now form part of your GP surgery team, giving people time to focus on what matters to them:

Our social prescribing link workers support patients aged 18 or over. Social prescribing works well for individuals who have:

• One or more long-term conditions

• Require support with low-level mental health issues

• Feel lonely / isolated

• Have complex social needs

Your appointment with the social prescribing link worked will usually be XX minutes and can be face-to-face, or via video or telephone call.

Appointments

You will be booked to see a social prescribing link worker by your GP surgery team where appropriate. You may also be referred by any other agency in Hounslow. If you think the social prescribing service could help you, you can also self-refer yourself to the service by completing this form.

As with all appointments provided by your GP surgery, if you cannot attend your appointment, please notify your GP surgery as soon as possible. This will help to make your appointment available for another patient. If it is a same-day cancellation, it is best to call your practice. Otherwise, you can contact your practice as you normally would.

Your appointment

Our Health & Wellbeing Coaches will be working across Hounslow to support PCN projects and Healthy Hounslow’s Health Check service. This is a mobile service and does not accept direct referrals, instead our healthcare professionals operate out of a converted ambulance and travel to different locations, events and communities across Hounslow. For more information, please visit the Healthy Hounslow website at healthyhounslow.co.uk/service/health-checks/.

If you would like to access health coaching on referral, the best way to access this service is to complete an online assessment on the Healthy Hounslow website, but if you prefer to speak to somebody about the service, then you will also find a telephone number.

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