Our case management service provides holistic assessments and care for housebound and non-housebound patients with physical, social, medication and psychosocial health and care needs from 9am to 5pm.

We see patients at home and in residential care settings. The service supports and encourages people with disabilities and long-term conditions to live independent lives.

The following can refer into this service:

  • GPs
  • Hospital consultant
  • Healthcare professionals
  • Non-healthcare professionals
  • Voluntary sector

Referrals are accepted through Merton Single Point of Access (SPA):

Inclusion

  • Housebound and non-housebound clients
  • Over 18 years of age
  • Unstable long term conditions impacting on the quality of life
  • Frequent A+E or GP attendance in last 12 months
  • Requires co-ordination and sign posting of health and social care needs
  • Requires medicine and/or chronic disease management
  • Socially isolated
  • Mild/moderate mental health issues
  • Recent hospital admission

Exclusion

  • Acutely unwell
  • Nursing home residents
  • Individuals at the end stage of life

The Merton service works Monday to Friday, 9am to 5pm.

The team undertake home visits.

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