We aim to facilitate independence/self management and optimum health/quality of life.

Long term Conditions; End of Life; Palliative Care.

We target patients with Long Term Conditions (LTC), who are high users of Primary and Secondary care.

The patient is required to be a resident in Central Manchester area, and has a GP who agrees to continue to maintain overall medical responsibility for care.

Service input involves supporting and educating patients and carers, proactively managing any health deterioration, carrying out medication reviews, following patients across boundaries with the aim of reducing length of stay in Acute Trusts.  Liaising and co-ordinating other services for the best interests of the patient.  All patients have an individualised care plan/management plan this is inclusive of an advanced care plan and use of the prognostic indicator tool and the thinking ahead documents.

They link in with the GPs across Central Manchester and cover nine nursing homes.

A full baseline history and clinical examination as appropriate to the presenting condition will be undertaken and documented for all patients within the Nursing Homes in Central Manchester.

An individualised care plan/Management Plan will be written and updated at each visit.

Patients who are considered to be entering the end of life phase and who require intensive daily support will be referred to the District Nursing Service (Residential homes only) and MacMillan nurses (in Residential and Nursing Homes) if required.

CHST covers 12 homes: 6 Residential and 6 Dual registered homes.

The Care Home Support Team covers 9 Nursing Homes in Central Manchester.

The service runs an open referral policy via the contact assessment form.

The patient is required to be a resident in Central Manchester area, and has a GP who agrees to continue to maintain overall medical responsibility for care.

If required patients will be seen whilst in hospital and in other PCT units such as intermediate care units.