1. Who can be referred to One Hackney? Anyone on the Frail Home Visiting list (and therefore with a care plan) Anyone in the 2% DES (High risk patients) Frequent healthcare users Either primary or secondary care We could define frequent? Patients with a history of poor engagement, compliance with existing care plans and challenging behaviours in relation to care providers/teams Patients identified as being vulnerable where this has an impact on provision of care for health needs This one may need further work up Patients where existing services cannot meet their health needs in a timely or comprehensive enough manner to prevent inappropriate healthcare usage Patients whose social situation means that they will struggle with self-care and/or compliance with an agreed care plan and where intervention is needed to reduce future healthcare usage appropriately Complex patients with 2 or more long term conditions where help is needed to coordinate their care

2. Other criteria for One Hackney referrals Service is open for anyone over 18 years of age Patients can be included in the One Hackney programme if they are registered with a City and Hackney GP Patients can be included in the One Hackney programme if they live within the borough of Hackney (even without a Hackney GP) There are some complications which are being addressed with boundary patients Those without a Hackney GP but living in Hackney Those with a Hackney GP but living outside of Hackney Referrals should be sent with an EMIS care summary and care plan if available Patient consent should be sought to refer to One Hackney before the referral is made. This should be indicated on the referral form

3. Other guidance on referrals Referrals should be made on a One Hackney referral form. In exceptional circumstances, referrals can be made by phone but all required information must be available If in doubt, referrers are strongly encouraged to ring the team to discuss a patient/client first An immediate acknowledgement will be sent to confirm that a referral has been received A follow up email will be sent within 5 working days to confirm that the referral has been accepted and who will be leading the case. This email will also include any details on the actions planned and confirmation of how feedback will be given If a referral is not suitable for One Hackney, the team will call the referrer to explain why the patient is not suitable and why they don’t meet the criteria (email only if referrer cannot be reached on the phone) and provide advice on the appropriate service to support the patient/client (ideally with contact numbers and information on pathway) The one hackney model is additional to existing services and aims NOT to duplicate any existing services Referrers should be encouraged to ask themselves can the patients care needs be met by referring to an existing service? If not – why not? The One Hackney model includes an advice and guidance function from expertise within the one hackney team. Advice and guidance is recorded as an activity within One Hackney.