Following referral to the Proactive Care pathway, patients are assessed by a Community Matron. This is a comprehensive assessment that looks at the needs and wishes of the patient.
The patient’s GP and the Community Matron will then present their assessment to the Multi-Disciplinary Team (MDT) for review. This is a virtual meeting chaired by a GP and attended by a Consultant Geriatrician, a Mental Health Support Worker and a Care Navigator from the voluntary sector. Other professionals will join the conversation as required e.g. community physiotherapist and social care manager.
These health professionals at the MDT will recommend any additional services that could benefit the patient and referrals are made directly by the professional in the room removing unnecessary bureaucracy.