Complex care team
The complex care team support people who have multiple complex health and social care conditions. Almost half of our patients are palliative and some are nearing end of life.
What we do
The complex care team support people who have multiple complex health and social care conditions.
Patients are supported in their own homes who have complex, multiple, long-term conditions and/or complex social situations. We liaise with many other teams to coordinate patient care and to support families and their carers
Living with complex, multiple health and social care conditions can be an upsetting time. It is important that an anticipatory/advanced care plan (ACP) is in place to ensure all the difficult conversations have taken place and that everyone concerned is aware of their loved one's wishes. This helps to reduce some of the stress at what is already a difficult and challenging time.
Often our patients have frailty - Frailty is a term that is used a lot, but is often misunderstood. When used properly it refers to a person’s mental and physical resilience, or their ability to bounce back and recover from events like illness and injury (e.g. UTI/Falls).
An advice line number is given to every patient/carer who is referred to our service for use if they feel that they need our support out-with scheduled home visit or have further queries.
Referral routes
Patients are referred via their GP surgery, other health care professionals and/or self referral. Patients must however consent to referral.
Location
Our service operates Monday – Friday 9am-4:30pm.
We give all of our patients a mobile number on which to call us if they feel that they need our support or have further questions after our visit.
At times we operate a short waiting list of 2-3 weeks, but we usually are able to visit the patient on the same week of receiving a referral.
We aim to contact the patient within a few days to arrange a convenient time to visit them at home.
Community complex care team: who we are
The Community complex care team are a small team that consists of:
- Frailty practitioner x 2
- Health care support worker
- Clinical psychologist
What is the complex care service?
The complex care team support people who have multiple complex health and social care conditions.
How do I refer to the complex care service?
Patients can ask their GP or health care/social care professional to refer to our team. Patients can self refer giving us their consent to access their information.
What can the complex care do for me?
We will come to your home for a discussion and assess your needs using our holistic-psychosocial approach. Once we have done our assessment including discussion with yourself and/or with other care givers (with your consent) we can sign post and refer you to services that may be able to make your home life a lot easier.
What is frailty?
Frailty is a term that is used a lot but is often misunderstood. When used properly it refers to a person’s mental and physical resilience, or their ability to bounce back and recover from events like illness and injury (e.g. UTI/Falls).
Other pages in Teams and services
Bladder and bowel service (BABS)
Care at home - end of life team
Children and families service
Community diabetes specialist nurse service
Community respiratory service
Community cardiac specialist nurse service
Fife specialist palliative care service
Marie Curie Nursing Service
MS nurse team Fife rehabilitation service
Motor Neuron Disease (MND) Specialist Nurse-led Service
In-patient palliative care occupational therapy team
Community palliative care occupational therapy team
Community palliative physiotherapy
In-patient palliative physiotherapy
Fife specialist palliative care adult counselling and bereavement services