The Midhurst Macmillan Service care planning/co-ordination process

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

The Midhurst Macmillan Service offers an innovative solution that provides end-of-life services to local people at home. This organogram illustrates the care planning/co-ordination process.

Midhurst Macmillan Service care planning process


Referral and assessment

A patient is typically referred to the Midhurst Macmillan Service by a GP or a consultant. A clinical nurse specialist (CNS) will carry out the assessment at the patient’s home. If the patient is in a crisis, the CNS will see the patient on the same day and do what is necessary to alleviate the crisis before carrying out a full assessment, including an assessment of the carers.

Assigning statuses

The patient is then assigned a status of zero, green, amber or red:

  • Zero indicates no admittance to the service at this stage
  • Green indicates that there is a need for some low-level input that can be provided over the telephone. The CNS will visit occasionally to check on the patient’s status
  • Amber indicates higher-level problems needing more complex interventions. A CNS will visit weekly and the clinical support team will be involved in providing care
  • A red status prompts several visits a week from the CNS and strong involvement of the clinical support team.

New cases are presented to the team at a daily meeting, and all patients are discussed at a weekly meeting. The CNS will assign the clinical support team to carry out agreed procedures and ensure the GP is informed. All team members interacting with the patient note their contact on the Crosscare system.

NHS continuing care team

In the last days of life, the NHS continuing care team takes over, with the CNS remaining the co-ordinator and point of contact for the patient.

See more of our work on co-ordinated care