The Proactive care service and Community Matrons offer comprehensive healthcare and support services tailored to individuals aged 18 and older who are living with frailty, multiple chronic conditions or complex needs.

The service goal is to empower these individuals to maintain their independence and overall, wellbeing within their preferred living environment, whether in their own home or a community setting.

The service provides personalised approach to care that aligns with an individual's unique needs and preferences, while also striving to address health inequalities and improve outcomes for the Enfield population.

The team works closely with our community matrons and other healthcare providers to deliver co-ordinated care through multidisciplinary team meetings, helping to prevent unnecessary hospital admissions.

The team is made up of the following experts

• Community Matron including case finders are senior, experienced nurses with enhanced skills who can prescribe medicines, undertake physical assessments and advanced care planning to help facilitate and promote patient independence without the need for hospital admission. Case Finders identify patients who may benefit from our services.
• Care navigators who help patients access services and resources.
• Peer workers offer support and guidance based on their own experiences.
• MDT Coordinator and Administrators, coordinates multidisciplinary team meetings, ensuring seamless communication, documentation, and follow-up across services
• Social workers, therapist, and Age UK supports with non-clinical interventions.
• A registered mental health nurse who provides specialised mental health support.

The service is available Monday to Friday, 9am-5pm.
e: RF-TR.nm.ProacticeCareService@nhs.net
t: 0121 289 7510

Eligibility Criteria

Inclusions

• 18+
• resident of Enfield and registered with an Enfield GP
• one or more long term conditions/disability
• frailty score 5-7 (moderate to severe) 
• individuals with long-term conditions who have recently needed emergency hospital treatment
• individuals who frequently consult their GP
• individuals who have health and support needs.

Exclusions

• under 18 
• acute or unstable mental/physical health 
• severely frail (frailty score above 7)
• non concordant to treatment/not consenting
• individuals that reside in care homes

How to Refer

Patients can be referred to the proactive care team through various channels

Locations

Lucas House

Pine Lodge