Complex Care at Home

The Complex Care at Home (CC@H) service is a preventative, proactive model of care provision that aims to support people at home using a Case Management approach.  The service runs in Cheltenham and Gloucester, weekdays from 8am to 6pm.

The team consists of Community Matrons / Case Managers, Dementia Matrons with a RMN qualification, Physiotherapists, Occupational Therapists, a Dietitian, Social Care Practitioners and Wellbeing Coordinators.

The CC@H service accepts referrals from GPs, Integrated Community Teams, Rapid Response, Specialist Services, the Enhanced Discharge Service, the Integrated Assessment Team and its voluntary partners.

Patients can be referred to the CC@H service by fax to 0300 421 6801 or or

Aims of Service

The CC@H service aims to proactively manage patients with complex health needs, in the community, who may previously have been high users of primary care and/or urgent care services. Using a case managed proactive approach to care, there will be a reduction in unplanned admissions to the acute services and/or a delay in escalation of their health and social care needs.

  • Proactive management of patients in the community who may have been previously high users of primary and urgent care services
  • Patients will be seen within 10 working days of referral being received
  • Use of a case managed coordinated approach to care
  • Person centred approach using the tool “My Life, My Plan”(see appendix a)
  • Support the person to improve their health and wellbeing by developing a patient centred partnership
  • Put the person and their family/carer at the centre of their treatment/care plans
  • Improve patient and carer experience
  • Reduction or delay in escalation to a care home placement, or nursing home bed
  • Better use of assistive technology, such as Telecare and Telehealth to support more patients at home

Exclusion Criteria

Referrals are not accepted for people who:

  • Are under 18 years of age
  • Have complex Mental Health (MH) issues affecting their ability to engage with services
  • Have complex MH issues requiring specialist mental health treatment or patients who are under the care of the Crisis Team
  • Are misusing alcohol or drugs to the extent that they are substance dependent
  • Very frail, with a frailty score of 8-9 already under the care of the Community Frailty Matrons
  • Entering or believed to be at end of life stage
  • Require emergency or urgent medical or social intervention/assessment
  • Are acutely unwell