The new CASS service is the first phase of work to transform community based health and social care services and incorporates existing services from Pennine Acute Hospital Trust Community and Manchester City Council.
CASS is a new integrated service delivery model that aims to avoid admissions (step up), reduce length of stay (step down) and improve citizen’s/carer’s experiences through better access to the right intervention, at the right time, delivered by the right health or social care worker.
The services in scope are as follows;
- Crisis Response,
- Intermediate Care (bed based)
- Intermediate care (home based)
- Some of the Primary Assessment Team
- Reablement Services.
The CASS service delivers rehabilitation to the citizen and carer promoting independence, and self management. The service is comprehensive and reflect citizens’ needs at distinct phases of care, identifying pathways and process models to ensure seamless transitions. It will provide high quality, evidence based, safe services, delivered in a personal and compassionate way.
Hours of operation
The Community Assessment and Support Service is available between 8am-5pm, with visits to deliver planned rehabilitative activity between 7 am-10pm, 7 days a week and 365 days a year
Crisis Response Assessments are available from 9am until 10pm, 365 days per year. The last referral will be accepted at 20.30pm
Out of Hours Service
Referrals or enquiries that cannot be assessed after 5pm will be prioritised. If unable to wait until an assessment can be completed the next day, the referral will be passed to the appropriate Out of Hours Team. This includes District Nursing; Go to Doc (Primary Care), Reablement out of hours team, Emergency Duty Social Work Teams.
Referrals to the service will come via many sources and include self referrals, Health Acute and Community Providers, Social Care Teams, Housing teams, Community Alarm Service, North West Ambulance Service, Mental Health Teams, Voluntary and Private Sector.
Referrals will be screened and triaged by the team so that the referral is followed up by the most appropriate worker within the service. Assessments that are required immediately in order to avoid hospital admission will be carried out by the Crisis Response team and will take place within 2 hours (1 hour if deemed high priority).
Contact telephone numbers for the service are as follows;
|CASS Team Point of Entry: Harpurhey District Offices
Telephone numbers 0161 667 3293/3292
Crisis Duty mobile 07816064131
|Crisis Referrals come through the team point of access
Any referrer who requires discussion on acceptance, criteria, or clinical discussion.
Trusted Assessments will also come through this point of access.
|CASS single point of Entry; Contact Centre
Telephone 0161 234 5001
|Normal Service Delivery|
|CASS Electronic Referrals
|Pennine Acute Hospital Trust-NMGH Intranet|
Referrals to the service will be in the form of electronic referrals, paper referrals or telephone calls. The electronic referrals will either be from Manchester City Council’s MiCare system, Integrated Care Gateway system, CASS NHS account or Pennine Acute Hospital Trust electronic referral system. The service will also take electronic referrals from North West Ambulance Service and all administrators will require access to their system which is known as ERISS.
Referrals can be accepted in the form of Trusted Assessment. Trusted assessments will be completed by nominated professionals who will either complete their own assessments and support plan or will complete the generic core assessment and support plan. These will be accepted and the planned intervention will be coordinated by the CASS service.
Telephone referral will be taken by the administrators or triage professional.
All paper copies can be faxed to fax number 0161 205 3649
All referrals will be passed to a professional/clinician who will triage the referral.
Registered with a Manchester GP or resident in Manchester –
Any acceptance and exclusion criteria and thresholds
The CASS will have a focus on inclusivity, and as such criteria is designed to be open to many clinical conditions, and states of being. The important aspect is that people are supported to access the most appropriate pathway to meet their needs.
Acceptance criteria are as follows:
- Consenting to the referral
- Have a suitable home environment to return to or remain in.
- Able to respond to a programme of care promoting rehabilitation and independence.
- Over 18
- Registered with a North Manchester GP or North Manchester resident
- Able to have medical and nursing needs met in the community
- Able to transfer with a maximum of two people and/or hoist
- Fit for transfer and deemed ‘medically fit’ if referred from an acute hospital bed
- Offered CASS service as close to their home as possible
Care Act Implications and Application
- CASS is considered a preventative service under the Care Act by Manchester City Council
- Care Act eligibility will ONLY be applied at the point of discharge, for those people for whom long term social care needs have been identified.
- A palliative condition or state has been identified, and no goals are achievable for improvement in functional ability. Intensive rehabilitation offered by CASS services would be inappropriate or unethical.
- People with severe enduring mental health issues and/or learning disabilities
- People age under 18 years
If any referrer or team manager needs any further clarification then please contact Carol Kavanagh, CASS Service Manager on 0161 667 3292.