Proactive Care team (PACT)
Description
The Proactive Care team (PACT) supports people over the age of 18 with long-term, complex health problems to access the right NHS services and manage their symptoms effectively. We support people to live more positively now and to face the challenges of tomorrow with more confidence, including older people who need support to remain independent or to plan for end of life.
Our services include physiotherapy, speech and language therapy, dietary advice, occupational therapy, advanced care and end-of-life planning and support. Our specialist Admiral Nurses support people with dementia and their families and carers.
Our services are in addition to services already provided by local GPs, primary care wellbeing services and community services. We work to address a person’s particular needs and priorities helping them to avoid unnecessary visits to their GP or A&E, or urgent hospital admissions. We can provide interpreters if required.
Please see our ‘for professionals’ section for referral criteria and other details for healthcare professionals, voluntary and community sector.
How to access our service
There are two ways to access the services of the Proactive Care team:
- GP referral – if you are registered with a GP in one of the practices listed below (see Location) you can be referred by your GP – unfortunately we do not work with GP practices outside of this specific central Bradford area.
- Self-referral – if you are registered with a GP in one of the practices listed below, you can refer yourself to the Proactive Care team by contacting us on 01274 256131.
Location
The Proactive Care team (PACT) only works with the GP practices listed below. The people we support must be registered with one of these practices in inner-city Bradford and will remain in the care of their GP, who should be contacted in the normal way for any urgent or emergency help. Our support is in addition to the services the GP provides and is short term.
- Bradford City 4 Primary Care Network – Kensington Partnership, The City Practice, The Lister Surgery, Picton Medical Centre, Bilton Medical Centre
- Bradford City 5 Primary Care Network – Dr Akbar, Thornbury Medical Practice, Primrose Surgery, Bradford Moor Practice, Farrow Medical Centre, The Avicenna Medical Practice, Valley View Surgery, Moor Park Medical Practice, Eccleshill Village Surgery, Peel Park Surgery, Bevan Healthcare Cic
- Bradford City 6 Primary Care Network – Kensington Street, Little Horton Lane – Dr Gilkar, The Family Practice, Little Horton Lane Medical Centre – Raja (Dr Mall), Grange Medical Centre, Parkside Medical Practice, Park Grange Medical Centre, Clarendon Medical Centre, Frizinghall Medical Centre, Bradford Student Health Service
- Five Parks PCN – Horton Park Medical Practice
How to contact us
The Proactive Care team can be contacted on 01274 256131.
Referral
If you have been referred to us, a member of our team will contact you to ask you some questions and book an appointment to see you for an initial assessment.
Waiting list
We aim to see you within two weeks of our first contact with you.
Assessment/appointment
We will arrange a time that is suitable for you and are happy for you to be supported by a family member or friend during the assessment. Our first appointment usually takes 90 minutes where we gather information to understand how your health is impacting your daily life.
After your appointment
We will discuss the information gathered during the assessment with the multidisciplinary team and formulate a plan that will be discussed and agreed with you. You will then be contacted by members of the team who will support you to achieve your goals.
Consent and confidentiality
Patient confidentiality is very important to us.
Our team will only contact you if you have consented. Personal information you tell our team will only be shared with your GP, and other health professionals involved in your care, if necessary.
We will not share your information with anyone without your permission, unless we are required by law; for example, if we believe you are, or someone else is, in danger or at risk of harm, or if we are told to provide information about you by a court or judge.
Introducing the Proactive Care Team
Our award-winning, experienced, multi-disciplinary and culturally competent Proactive Care Team (PACT) works to enable prevention, recovery and sustainability so people can live well and avoid unnecessary A&E, urgent care admissions and visits to primary care.
PACT is supported by Bradford District and Craven NHS Clinical Commissioning Group and delivered by Bradford District Care NHS Foundation Trust in partnership with Bradford Teaching Hospitals NHS Foundation Trust, Dementia UK and City Health Bradford GP Federation.
How to contact us
For more information about the Proactive Care Team, or to speak to a team member about a referred service user, please contact us on 01274 256131.
How to refer
Please read the referral criteria below for both the Proactive Care Team and Admiral Nurse Service and to refer for either, please use the Proactive Care Team’s e-referral form on SystmOne.
PACT referral criteria
Adults aged 18+ who are living with two or more non-communicable conditions, persistent physical symptoms or frailty, leading to frequent attendances at primary and secondary care services, falling through gaps, poor quality of life and patient dissatisfaction.
Enhanced levels of support will be provided to meet exacerbations of need for a defined period.
| In scope | Out of scope |
| Residents registered with a CP4, 5 and 6 general practitioner | Residents not registered with a CP4, 5 and 6 general practitioner |
| 18 years plus with multimorbidity | Under 18 |
| Complex social, emotional and psychological needs that impact on health and wellbeing | People with uncomplicated needs that could be met through ‘statutory’ teams/services |
| People whose needs are impacting/likely to impact on avoidable use of primary and secondary care | |
| People in the last 12 months of their life |
Admiral Nursing service referral criteria
The person with dementia must have a confirmed diagnosis of a dementia, made either by a Memory Service or Consultant.
The person with dementia is experiencing complex symptoms and carers are strugging to cope and would benefit from specialist, focused support.
The person with dementia or their carer has consented to the referral and receipt of the service.
Exclusions
The primary need of the person with dementia, carer or family is not related to the dementia (for example a significant mental health problem requiring a different service, or underlying physiological problems which could be causing neurological impairment)
Head injury that is a primary diagnosis to cognitive impairment.
Crisis management requiring response within 120 hours.
Find out more about the Proactive Care Team in this video: