PACT is a proactive care service for frail older adults, and their carers, living in our community. Our aims are to intervene early, to identify what is important to the patient using a personalised approach, and to utilise appropriate local services to support the patient to remain well at home.
As part of the PACT review, patients will be offered a comprehensive geriatric assessment, structured medication review, advanced care planning, Universal Care Plan, Multidisciplinary Team input and referrals to social prescribing and other local voluntary services.
Following PACT intervention, residents should be empowered with a greater understanding of their health and wellbeing, including supported self-management plans, knowledge of how to identify deterioration in their health and where to get early support. Ultimately, our aim is to support our residents to live well and age well in the community.
Meet the Team
- Two Advanced Clinical Practitioners (one nurse ACP and one physiotherapist ACP) – residents will see one of the ACPs in their own home, or at St George’s Health and Wellbeing HUB. It is the ACP’s role to carry out a holistic and comprehensive assessment of the resident’s medical, nursing, mobility, nutrition, psychological and social needs, as well as the needs of their carer/s.
- Care Coordinator – who will contact residents to arrange appointments, schedule follow-ups, act as a point of contact for any resident queries and follow up on referrals.
- Frailty Social Prescriber – who follows up all residents who are seen by PACT to identify any non-medical needs that may be impacting on the individual’s health and wellbeing, and link them to additional support in the community.
Criteria
Inclusion Criteria:
- The service will be provided to adults over 65 years of age who are living with frailty and are registered with a GP in any of the 5 practices covered by Havering Liberty PCN (including temporary residents).
- Housebound residents will be prioritised, as they often experience health inequalities when accessing usual services.
Exclusion Criteria:
- Permanent resident in a Havering Care Home.
- Service users may be excluded from services in line with the NHS Zero Tolerance Policy.
How to refer?
All referrals can be made by emailing:
We will accept referrals from any person or service working with older people in the community.
Residents can self-refer too by phoning 07481 609410, or by sending an email to the named email account above.
Pathway once a referral has been received by PACT
Once the referral has been received, it will be reviewed for suitability. For any rejected referrals, the service provider will be contacted by the Care Coordinator who will explain the reasons for the rejection.
For accepted referrals, the Care Coordinator will contact the resident and introduce the PACT service, explaining all that it entails. If the resident consents, an appointment will be made (usually within one week).
Following a comprehensive assessment from one of our ACPs, our Frailty Social Prescriber will call to ensure that the resident is provided with additional community support to continue living well at home.
After the resident has received the assessment, onward referrals and social prescribing support, they will be discharged from the PACT caseload.
However, all residents may contact the care coordinator for further assistance – for example, to chase up any referrals made, or if there is a change to their situation and a further assessment would be beneficial.