Bromley Care Coordination at St Christopher’s – Information for Professionals

Who we are

Bromley Care Coordination (BCC) is provided by our expert team at St Christopher’s and commissioned by Bromley Clinical Comissioning Group. The service enables patients with advanced illness, multi-morbidities and frailty to receive timely and coordinated care in the community.

The BCC core team consists of clinical nurse specialists, staff nurses and healthcare assistants who are able to draw on the expertise and support of other healthcare professionals from St Christopher’s, as required. The emphasis of the service is on care coordination and aims to help older people and their families to navigate the health and social systems.

What you can expect from us

The BBC Team can:

  • offer advice and support to health and social care professionals caring for patients whose condition is deteriorating and changing
  • extend good care to more people and enable them, wherever possible, to be cared for and die in their preferred place
  • reduce unwanted and unnecessary hospital admissions in the last year of life and
  • add patient details and care preferences (with their consent) to the Coordinate My Care register.

Whom to refer

You can refer any patient thought to be in the last year of life. Indications for referral include:

  • People with an EFI of severe frailty (>0.36 over 13 defects)
  • Thought to be in the last year, with:
    • multiple admissions to hospital in the last year
    • increasing uncertainty
    • deterioration
  • Long term comorbidities (rather than an acute event), including:
    • cardiac (heart failure, cerebrovascular accident)
    • dementia
    • endocrine (e.g. diabetes)
    • neurological (e.g. motor neurone disease, multiple sclerosis, Parkinson’s)
    • cancer
    • renal failure
    • respiratory
  • Precarious social support network/carer burden and escalation of concern
  • Would benefit from advance care planning or discussions about the future
  • Requires a joined-up approach – currently falling between services and requires care coordination.

How to refer

Professionals can refer directly by telephone on 020 8768 4500 via our Single Point of Contact team (SPoC) or via email at st.christophers@nhs.net. For more information, please contact the Service Lead/Consultant Nurse on 020 8768 4500. On referral we would expect guidance on the following:

  • Has the patient given permission for the referral?
  • Does the patient have capacity?
  • Who is the next of kin and do they know about the referral?
  • Are there any issues with access to the patient e.g. sensory deprivation or do they live alone?

St Christopher’s Bromley Care Coordination is only for patients registered with a Bromley GP.

How to contact us

Do not hesitate to contact us on 020 8768 4500 if you have any worries or concerns regarding a patient. We offer a 24 hour telephone service for professionals and patients which is staffed out of hours by a clinical nurse specialist until 10pm and then the duty doctor.

Both will be able to offer advice and arrange a visit if required.