Community Assessment and Support Service (CASS) – North Manchester

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 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.

Registered with a Manchester GP or resident in Manchester.

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

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.

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).

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 referrals will be passed to a professional/clinician who will triage the referral.

Contact telephone numbers for the service are as follows;

CASS Team Point of Entry: Harpurhey District Offices

Telephone numbers: 0161 667 3293/3292

 

 

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

Hours of operation

The Community Assessment and Support Service is available between 8am – 5pm, with visits to deliver planned rehabilitative activity between 7am – 10pm, 7 days a week and 365 days a year

Crisis Response Assessments are available from 9am – 10pm, 365 days per year.
The last referral will be accepted at 8:30pm

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.