South Tyneside Personalised Care Teams

 

First Contact Clinical support a number of partners and pathways across South Tyneside and we have organised our capacity into place-based personalised care teams. In addition, we have a gateway team, a team of workers supporting locality wide pathways. 

Our personalised care teams support individuals using a person-centred approach. We use the Patient Activation Measure (PAM), where appropriate, to understand a person’s level of activation. Patient activation describes people’s skills, knowledge and confidence to manage their own health care (self-manage, or self-care). We use PAM to ascertain how equipped an individual is to make a change, then tailor our intervention to suit. PAM Level 1 and 2 individuals are less equipped to make a change and may need a longer and more intensive intervention than those who are a PAM Level 3 or 4.

We support individuals to;

  • increase their knowledge, skills and confidence, enabling long term sustainable behaviour change
  • develop coping skills and strategies for when things aren’t going so well
  • support individuals to identify any unmet non-medical needs including but not limited to social, emotional and financial needs
  • engage individuals with services that can help meet these identified needs
  • improve an individual’s knowledge about other local services and community resources

The scope of our work includes:

  • People with long-term conditions
  • People who are high intensity users of unplanned services, in primary care and secondary care
  • People with non-medical needs, i.e., social and emotional needs
  • People who are supported by the Integrated Care Teams and Social Care Teams
  • Veterans
  • People at risk of offending or re-offending
  • People at rish of loosing housing due to anti-social behaviours

Our personalised care teams contain the following roles:

Social Prescribing Link Workers (a "social" focus)

  • Support people to build their knowledge, skills and confidence to self-care
  • enable people to change their health-related behaviours
  • introduce or reconnect people to community groups and statutory services

Health & Wellbeing Coaches (a "health" focus)

  • support people to build their knowledge, skills and confidence to self-care
  • enable people to change their health-related behaviours

Care Coordinators

  • provide coordination and navigation of care and support across health and care services
  • act as a central point of contact to ensure appropriate support is made available to address their changing needs

We work closely with our VCSE partners, who are key in ensuring we have knowledge of the wide range of activities, groups and services that can support the people we work with achieve their goals.

 

You can make a referral via fcc.abu@nhs.net or by calling 0191 4324582.

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