The Multi-Agency Care and Coordination (MACC) Team is a proactive and preventative care service for adults living with frailty or complex long-term healthcare needs. It accepts referrals and also works in partnership with Haringey GP practices and other trusted professionals to identify those who may benefit from support.

MACC is an integrated team of professionals from multiple disciplines and agencies.

The team includes:

• MDT tele-conference
• Social workers
• Mental health workers    
• Occupational therapists
• Physiotherapists
• Navigators    
• Pharmacists
• Community matrons
• A general practitioner

What MACC can offer

As an anticipatory care service, MACC aims to keep people well, work towards their goals and reduce avoidable hospital attendances or crises.

Referrals will be triaged by a senior clinician and if accepted, may be proposed to MDT teleconference, and/or receive a holistic assessment (comprehensive geriatric assessment where appropriate). 

MACC can provide tailored interventions to support the client's medical, functional, mental health and social care needs. 

Adopting a patient-centred approach, the service sets goals with its clients and create personalised care and crisis plans.  

It will work in partnership with professionals already involved in a client's care to provide wrap-around multi-disciplinary support. It is well placed to link clients with other services and support their needs.

Eligibility Criteria

Inclusions

• Adults living in borough of Haringey registered with a Haringey GP
• People living with moderate or severe frailty with rising risk; Electronic Frailty Index (eFI) ≥0.25 or Rockwood Clinical Frailty Score of 5 or above. Please see Clinical frailty scale (nice.org.uk)
• People living with multiple and/or complex long-term health conditions (including dementia) who would benefit from MDT input
• People who require coordination of their care, whether already known to multiple services or not
• People who have frequent unplanned hospital admissions and are at future risk of this continuing
• People who are carers themselves where the care is at risk of breaking down

Exclusions

• Where the sole need can be met by a single service (e.g. package of care only or for major adaptation = social services; acute mental health crisis = BEH; rehab therapy input = ICTT)
• Immediate admission avoidance cases or those who need to be seen within 12-24 hour (Rapid Response)

How to Refer