A complex care team in York has received a big thumbs up in a recent survey for helping the city's most vulnerable patients.

The Complex Care Team (CCT), based at York Medical Group, has just received a high approval rate with 96 per cent of patients who responded to the survey saying their experience of the service was 'very good', or 'good'.

The team, which began in 2019, coordinates special, individual care to vulnerable patients, originally with the aim of looking after those receiving end of life care. But during the pandemic, the team helped to support other vulnerable patients, who needed help to navigate complex health and care systems.

The team’s case load includes patients living with dementia, severe mental illness, cancer, heart problems, chronic obstructive airways disease, learning difficulties and many other long-term conditions.

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An example of the work they do includes supporting a man, 98, who was worried about who was going to look after him after his wife died.

Emma Oldfield, the Complex Care Lead, said: "We looked closely at what sort of support these vulnerable patients needed and formed a team who could coordinate exactly that – supporting not only the patients, but their families as well.

"We reached out to the patients to look at what we could do to support them and formed a team and service which could help them."

During the last year, the team have reviewed the long term conditions of 236 housebound patients, resulting in improved health outcomes and reduced hospital admissions.

To help them achieve this, they have conducted home visits, developed care plans, organised regular reviews, screening, and worked with social services and prescribers.

During the pandemic, they administered Covid vaccinations to housebound patients, and identified many who needed additional support, so set up a visiting team.

They have signposted more than 100 people to bereavement support and made sure patients who are end of life have specified where they would prefer to die.

One patient has left the following feedback to the team recently: "Every time I phoned you I was always greeted by a friendly, helpful voice.

"You have no idea how much I needed that some days!

"It’s been an emotional journey caring for our lovely Dad since March and your team really did make a difference especially on those days I could hardly talk for tears. Thank you for all your help.”

The team listen to patient feedback to continue improving their service, such as they changed the invitation letters for patients with learning difficulties to an easy read format and changed the times of the clinics as they were finding it difficult to make early morning appointments.

Through all their dedicated hard work, the team have achieved significant improvements in all the Quality Improvement Plan (QIP) areas, which is one of the main assessments done to improve care in the NHS.