The Multi-Agency Care and Coordination Team (MACCT) is a proactive and preventative care service for adults living with frailty or complex long-term healthcare needs. Haringey's MACCT is an early example of an integrated neighbourhood team model, driven by the fundamental first question of "what matters to you". It brings together more than 30 professionals from a wide range of disciplines.

The team includes:

• multi-disciplinary team (MDT) tele-conference
• social workers
• mental health workers
• occupational therapists
• physiotherapists
• navigators
• pharmacists
• community matrons
• a general practitioner

What MACCT can offer

The MACCT work together to identify, plan and coordinate care for people with complex needs. Most people supported are older adults living with frailty, but not exclusively. 

MACCT is a partnership between Whittington Health NHS Trust, Haringey GP Federation, North London Foundation Trust (who provide specialist mental health services), Haringey Council and Bridge Renewal Trust. The service works across three neighbourhoods: East, West and Central, in line with other local community services.  

Find out more by watching the short video Inside Haringey's MACCT: Delivering on the Government's Long Term Plan for Neighbourhood-Based Care.

If you would like the team to work with you in a development capacity to share their learning about integrated working, improve links with your Haringey Service or any other development opportunities, contact the team managers on whh-tr.MACCT@nhs.net to discuss further or call on 020 3074 2958.

Referrals to the MACCT

Referrals are triaged by an experienced senior clinician within 24 hours. The information is reviewed across multiple record systems (GP, hospital and social care) and use professional judgement to direct the person to the right support stream.

• Stream 0: Weekly multidisciplinary team meetings, a forum for discussing complex needs and agreeing shared actions.
• Stream 1: Outreach and erly identification, case-finding people with mild to moderate frailty from GP lists for early support.
• Stream 2: Escalations from stream 1, managed by a single professional. Includes people whose referrals were rejected elsewhere or don't meet the criteria for other services.
• Stream 3: Prompt action on rising risk, joint working by two or more professionals to address complex needs early and avoid crisis.

All referrals are responded to, even if not suitable for the MACC team. Residents are referred on or signposted to the right service. Referrals are only returned to the GP if no other option is available.

Eligibility Criteria

Inclusions

• adults living in the borough of Haringey registered with a Haringey GP
• adults living in Haringey or within a mile of the Haringey boundary and have 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 = North London Foundation Trust; community rehab therapy input = HURT/HART; specific nursing intervention (continence assessment, wound care, medication support = District nursing team)
• immediate admission avoidance cases or those who need to be seen within 12-24 hour (Rapid Response 020 7288 3670)

Though MACCT is not an acute service. They aim to triage referrals within 24 hours (excluding weekends and bank holidays). Following triage, your patient will be contacted and assessed dependant on clinician prioritisation (the service operates on a 6 week maximum waiting time).

If you feel that a person is at immediate risk of hospital admission or imminent care breakdown, refer to the Rapid Response service via their registered GP or directly.

How to Refer