-
Topics
- All Topics
- Self Care
- Blood & Skin
- Cancer
- Cardiovascular & Respiratory
-
Children & Family
- Child Emotional Wellbeing & Mental Health
- Children, Young People & Family
- Domestic Violence & Abuse
- Female Genital Mutilation
- Gender Identity Adults
- Homelessness
- Learning Disabilities
- Migrant Health
- Neurodiversity
- Safeguarding Adults
- Safeguarding Children
- Sexual Health
- Social Prescribing
- Speech & Language Therapy
- Diabetes & Endocrine
- Diagnostics & Investigations
- Frailty & Complex Care
- Gastroenterology, Colorectal, Renal & Urology
- Head, Neck & Eyes
- Infectious Diseases
- Mental Health
- MSK
- Neurology & Neurosurgery
- Nutrition & Weight Management
- Obstetrics & Gynaecology
- Social Care & Safeguarding
- Urgent & Emergency
- Clinical Pathways
-
Medicines
- Controlled Drugs
- Electronic Prescription Service
- Infections & Antimicrobials
- Medicines Compliance
- Medicines Optimisation Prescribing Policies
- Medicines Optimisation Team
- Medicines Supply Issues
- Patient Group Directions
- Prescribing Guidelines
- Prescribing Quality Scheme
- Prescribing Recommendations
- Self-Care Medicines Scheme
- Shared Care
- Fact Sheets
-
Practice Management
- Cancer Care Resources
- Deadlines
- Enhanced Services
- GP Feedback and Alert System
- General Practice Change Management Support
- General Practice Staff Survey
- Greener NCL: Sustainable General Practice
- Hospital Bypass Contacts
- Immunisations & Vaccinations
- Practice Vacancies
- Referral Support
- Research Opportunities
- Support for Staff
- Working Well Across the Primary Care-Secondary Care Interface
- Education
- Digital
Proactive care service & Community Matrons
EnfieldProvided By
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 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. Professionals involved include community matrons, mental health nurse, care navigators and peer workers.
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. Please see below.
EMIS form
Referral methods: Email
Direct referrals: Primary care providers, secondary care specialists, and other stakeholders can refer patients directly.
Complete the Adult Services Single Point of Access Referral Form - Enfield Community Services and send to rf-tr.ecsadultsinglepointofaccess@nhs.net
Once the referral has been received, it will be screened by non-clinical administrators with no changes to clinical response times.
Multi-disciplinary team meetings: Healthcare professionals can discuss patient cases and determine if referral is appropriate.
Risk stratification tool: An electronic method used to identify patients at risk of frailty or complex needs.
Where to find the form
- Enfield: ENF Global Library > Community Therapies folder
Related Services
Community Matrons
To prevent avoidable hospital admissions through the case management of patients with complex needs HaringeyCommunity Matrons
To prevent avoidable hospital admissions through the case management of patients with complex needs IslingtonRelated Topics View All
Community Clinic Services
Community commissioned clinics and services within NCL (non funded by Local Authority Borough)Frail & Elderly
Information about frail and elderly services across NCLReview date: Sunday, 07 March 2027