The BILT team is an integrated team of health and social care staff who provide case management and care navigation to adults with complex needs in the community.
The team are based at one location and work with the person to identify person centred goals and coordinate their care. They have links to other specialist community services and the voluntary sector. The team also contribute to the Frailty MDT which is a consultant led meeting to review elderly people who are frequent attenders to hospital or have complex health needs.
Risk stratification is in place to identify patients in GP practices who may benefit from case management. Patients are also referred via social care, acute hospitals and other community teams.
Only GPs can refer to this service.
- Inclusion: 18+ complex needs in the community requiring integrated health and social care approach.
- Exclusion: People whose needs are being well met by other services.
Home visits are available for this service.
Edgware Community Hospital
Burnt Oak Broadway,
Opening hours: 9am to 5pm.