PACT aims to proactively identify and support people living with frailty and complex health needs to live at home healthily.

The PACT team is able to help coordinate care for patients who may need help from multiple areas, in addition to supporting their healthcare needs. It aims to connect providers, resources and facilities to ensure a holistic, integrated care for the Southend West Central community.

Led by our Clinical Team Leader Lionah and PCN Nurse lead Kayley, the team can take referrals from GP practices, the hospital discharge team and other partners for patients in the following categories:

• Frail and elderly
• Hospital readmissions
• Hospital discharges
• Frequent attendees to practice
• High risk of being hospitalised
• Vulnerable at home

Following an assessment, any necessary referrals will be made to relevant professionals from the many different teams that PACT works with, e.g. Social Services, Dementia Intensive Support Team, Carers Intensive Support Team and the Complex Care Co-ordination Service.

Following this, welfare reviews and progress checks are undertaken.

Patients will be with the team for up to 30 days, or when discharge has been agreed by the PACT lead.