The Esteem Team care planning/co-ordination process

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Part of Co-ordinated care for people with complex chronic conditions

The Sandwell Esteem Team deliver a holistic primary and community care-based approach to improve social, mental and physical health and wellbeing in the borough of Sandwell. This organogram illustrates the care planning/co-ordination process.

Sandwell Esteem Team care planning/co-ordination process


Initial assessment

Once a patient is referred to the Esteem Team, a link worker carries out an initial assessment as soon as possible (within three days of referral or immediately if the crisis appears to be acute), usually at the patient’s home.

If the link worker identifies an urgent need, they will initiate interventions as required directly after the assessment, for example, contacting social services if there is a housing issue such as overcrowding. The link worker also identifies carers and informs them about services available to them through the Sandwell Wellbeing Hub such as respite, information and peer group support. They ensure they are put on the carers’ register, which triggers an assessment and support process by the local authority and entitles carers to benefit payments.

Assigning cases

The Esteem Team meets weekly to discuss new and existing cases. Cases are assigned a colour code of red, amber or green depending on their complexity. In some cases link workers will take on patients with whom they have had a previous relationship.

Action plan and referrals

Following assessment, the link worker visits the patient, creates an action plan and discusses suitable therapies. The action plan also includes steps to address a patient’s social problems. The link worker arranges for referrals to services.

Throughout their relationship, the link worker seeks to bolster the patient’s confidence and self-esteem by offering them step-by-step actions that the patients can implement at their own pace, creating a sense of achievement. The link worker will also invite the patient to use self-assessment tools to measure their wellbeing and to chart progress. If no progress is made, the action plan is revisited to discuss alternative therapies and services.

Interventions and discharge

There are no defined care packages, but care co-ordinators seek to provide interventions that can benefit the patient. Patients stay in the esteem service as long as they need support. They will be discharged when the link worker and the clinical co-ordinator feel that they have improved enough to benefit from lower level services. Link workers will usually encourage patients to make use of these services early on to include them socially and to put them in touch with other patients in similar situations.

In the lower-level interventions, people may never leave the service and continue to attend community support groups. Some get involved as volunteers.

See more of our work on co-ordinated care