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Patient referral, review and developing a care plan

In this section we look at how we receive the referral, review the case and develop a care plan.

  • Initial referral and internal process

    Referral information is received by the unit in a number of ways, by telephone, dedicated email or correspondence from both external and internal sources. The allocated officer will carry out a call volume search to determine if the patient falls within the defined criteria. Cases are recorded using a case management system.

    If the patient does not meet the criteria the case is closed and the referrer advised accordingly, although monitoring can be maintained so that we can be proactive about any future issues.

    If the patient meets the defined criteria, the patient’s GP details will be obtained and call volume details recorded and made available to the patient’s GP. If the patient is not registered with a GP, the clinical commissioning group or other relevant agency will be approached.

    The unit reviews and updates approximately 140 cases each month. This review monitors any increase or decrease in 999 activity. Where appropriate, the relevant agencies involved in the patient’s care will be notified and a case conference arranged.

    Where appropriate, patient-specific protocols or individual-dispatch protocols are agreed with the patient and the involved agencies and signed off by our Medical Director. These are held on our locality information system (see below) so as to alert the 999 call handler, and/or the attending ambulance crew, as to what action has been agreed. A full copy of the plan is held by our clinical support desk, who are responsible for the day-to-day management of the plan.

  • Local structure within ambulance complexes

    Each local ambulance station complex has a responsibility for the local authority and clinical commissioning group area and patients under the unit’s management are aligned to a complex based on geographic location. Each local ambulance station complex has a nominated representative who is allocated responsibility to work with the unit to review all cases in the area.

    The unit assists local representatives with this portfolio to enable the development of skills and processes involved in building local contact networks, so that future cases can be undertaken locally with the unit playing a supporting rather than a lead role.

  • Local multi-disciplinary forums

    Invitations are made to the local authority social services, primary care, mental health and acute trusts and other relevant agencies to establish a regular forum to enable specific care plans.

    This also allows health and social care colleagues to advise us of any patients that may similarly be posing problems to the respective agencies where we may be able to play a role in setting up an appropriate care pathway. An additional benefit is that this allows issues to be raised beyond the limits of this particular area of work.

  • Case conferences

    The patient, carer and advocate are always invited to participate. Written notification is always provided. All clinical care issues are agreed by our Medical Director.

  • Information sharing protocols

    Information sharing protocols are agreed with partner agencies, where necessary.

  • Reporting and governance

    Activity reports are made available to our local area committees, Clinical Governance Committee and our commissioners. An annual report is published on our website and made available to NHS London.

  • Locality information

    Our locality information database is made up of three categories:

    1. Individual-dispatch or patient-specific protocols – care plan or other arrangements in relation to individual patients.
    2. High risk register – patient addresses where a previous incident has occurred that poses a potential risk to ambulance staff.
    3. Safeguarding – unborn children deemed to be at risk by safeguarding professionals and the police.