Document type

n/a

Place

South and West Hertfordshire

Output type

Clinical Pathways

Pathway

Complex Case Management, Locality MDT, and Frailty Clinics

Complex Case Management, Locality MDT, and Frailty Clinics

 

This service is available to those patients identified as most vulnerable in the community with long term health conditions and at risk of recurrent or avoidable hospital admission. It is a Multidisciplinary approach aimed at coordinating community health services, social care, voluntary and GP services to support the patient in their own home. The service is available to all patients, including those in care homes and those with learning disabilities

Referrals are received via the ‘Community Complex Case Management (CCM) including Locality 

Multidisciplinary Team (MDT) Intervention and MDT Frailty Clinic’ referral form. 

Please see pathway attached for further information.