Complex Care Team


Who are we?

We are York Medical Groups complex care co-ordinators; we are here to help you. We liaise closely with your GP to provide continuity of care. Our aim is to ensure you feel supported and have access to the services that are right for you. We develop tailored personalised care plans for patients identified with significant long term and complex health issues and social care needs.

To give you an idea of how we can help:

  • We work closely with the home visiting team and GPs to ensure continuity of care and arrange home visits.
  • Telephone patients after discharge from hospital to ensure they have the support they require.
  • Refer to District Nurses or Palliative care support.
  • Support Care home, residents, and their families.
  • End of life/Complex Needs.
  • Arrange dementia, learning disabilities and mental health reviews for patients.
  • Liaise with Social services to co-ordinate care.
  • Visit our house bound patients to deliver vaccines and long-term condition reviews.
  • Refer carers to specialist support to help them look after their loved ones.
  • Arrange for Social Prescribers to offer support and sign posting to other services.
How can we help you?

If you are living with a medical condition and require some additional support we are here to help!

Equally, if you are a carer for somebody else, we are available to help both you, and the person you care for.

Finding the right support can be a difficult and daunting task. We can help you find the right path to follow by providing information on local services.

What we can help you with
  • Befriending and Bereavement Services
  • Finding Care Providers
  • Funding Support including Social Services
  • Meals on Wheels
  • Be Independent
  • Sensory Services (for Hearing and Sight Impairment)
  • Support for Carers
  • Transport
  • Weight Management/ Health and wellbeing
  • Wheelchair and Equipment Hire
  • Future Care Planning
  • General Advice and Information
  • DNAR forms
  • Social Services
  • Social Prescribers
  • Mental Health Support
  • Dementia and Alzheimer’s Support
  • Learning Disabilities

What Next?

If you think you would qualify for support from the CCT please ask at your next appointment or speak with the reception team who can make a referral to us.

York Medical Group Complex Care Team

Emma Oldfield, Melanie Benfield, Michelle Moss, Jo Archer, Crystal Mooney, Philippa Millward, Ginny Barrett and Fran Bowser