Collaborative Care Team

Leading Healthier Lives

Collaborative Care Team

The Collaborative Care Team (CCT) offers support to patients who are 18 years+, considered vulnerable with complex needs.

The team have a wide clinical skill set and many years of professional experience, covering physical health, mental health, substance misuse and referring them to the appropriate services to prevent hospital admittance and enable patients to live a healthy lifestyle in their own homes.

Collaborative Care Team | General Practice Alliance

Eligibility Criteria

  • If they are experiencing physical and/or mental health concerns
  • If they require Talking therapy
  • If they require Occupational therapy
  • If they require advice on benefits
  • If they need support with resolving medication issues
  • If they have long-term health conditions
  • If they are frequent attenders to practices and hospitals
  • If they require clinical advocacy and support
  • If they require safeguarding and social care needs
  • If they require mental health interventions including learning disabilities and neurodiversity

Length of Intervention

The CCT will usually work with patients for up to 12 weeks, however, sometimes this can be longer if they are resolving complex issues.

Appointments and Referrals

When you are referring a patient to the Collaborative Care Team, you will need to refer via SystmOne > Patient Consultation > Search CCT.

When referring, you will need to be as specific as you possibly can as to why you are referring and what your concerns are so that we can appropriately engage with the patient.

Frequently Asked Questions

The Collaborative Care Team is not an emergency service, and it can take up to an average of two weeks for patients to receive an appointment after referral.

Yes. However, if someone from the practice, i.e. GP/Clinician has identified a safeguarding issue, it is up to them to refer the patient to the safeguarding team (Adult Social Care).

Yes, we do. We work very closely with: Adult Social Care, Mental Health, Pharmacists, Community Occupational Therapists, and any other appropriate services.

  • Conduct low-level OT assessments if required
  • Provide exposure work
  • Support patients in accessing support groups and day centres
  • Provide access to Alpha-Stim Relief from Anxiety, Insomnia, and Depression & Pain (here)
  • Arrange MDT meetings with the option to represent the GP

All patient data is submitted on SystmOne so that GPs and other appropriate services using this system can access if required.

When CCT has discharged the patient due to completion of the care plan, information is sent directly to the referrer/GP.

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