Who are we?

We are York Medical Groups complex care co-ordinators; we are here to help you. We liaise closely with your GP to provide continuity of care. Our aim is to ensure you feel supported and have access to the services that are right for you. We develop tailored personalised care plans for patients identified with significant long term and complex health issues and social care needs.

To give you an idea of how we can help:

• We work closely with the home visiting team and GPs to ensure continuity of care and arrange home visits.
• Telephone patients after discharge from hospital to ensure they have the support they require.
• Refer to District Nurses or Palliative care support.
• Support Care home, residents, and their families.
• End of life/Complex Needs.
• Arrange dementia, learning disabilities and mental health reviews for patients.
• Liaise with Social services to co-ordinate care.
• Visit our house bound patients to deliver vaccines and long-term condition reviews.
• Refer carers to specialist support to help them look after their loved ones.
• Arrange for Social Prescribers to offer support and sign posting to other services.