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Long-Term Care

Long-Term Care
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National Network of Long-Term Integrated Care  ReferentiationCoordination Teams

  • The National Network of Long-Term Integrated Care is an organizational model created by the Ministries of Labour, Social Security and Health and is formed by a group of public and private institutions that provide long-term healthcare and social support.

  • Users may be proposed to the Network through one of the following options:

    If they are admitted to a NHS hospital through the Hospital Discharge Team

    The Hospital’s Discharge Team aims to prepare and manage hospital discharges in articulation with other services, for patients who require follow-up of their health and social problems (Decree-Law n.º 101/2006, 6th of June).

    • Contact the service where you are hospitalized or the Hospital’s Discharge Team;
    • The Hospital’s Discharge Team should make the referentiation to the National Network of Long-Term Integrated Care. The assessment on the need for long-term care is preferably carried out at the beginning of the hospital stay because it´s necessary to timely prepare the stage following clinical discharge.
    • The proposal of this team is presented to the Local Coordinating Team (ECL).

     If they are in the community through the Health Centre

    Contact the local health centre through:

    • General Practitioner (GP);
    • Nurse;
    • Social worker.

    The proposal to join the National Network is presented by these professionals from the health centre to the Local Coordinating Team.

    For further information, contact the Local Coordinating Team placed at the health center in your area of residence.

     

    The referral can be made to the Network of Long-Term Integrated Care for Mental Health (CCISM) in the following circumstances:

    1. If you are admitted to a hospital of the National Health Service through the Local Mental Health Service, hospital or psychiatric hospital where you are.

    • The health professionals of the unit/hospital where they are hospitalized refer the users for potential admission to the National Network of Long-Term Integrated Care (RNCCI).

    2. If you are in the community (home, private hospital or other place of residence)

    • Referral by the health professionals of the Functional Units (Family Health Units or Personalized Healthcare Units) of the Health Centre Groups.
    • The referral proposal is presented by the professionals of the hospital services or functional units mentioned above, to the Local Coordinating Team (ECL).

    3. Users who are in a psychiatric institution of the social sector

    • Are referred by the service itself

    4. Children and adolescents (between 5 and 17 years)

    • Children and adolescents (5 to 17 years old) who are in mental health services/units for childhood and adolescence are referred by this service or unit.
    • The referral proposal is presented by the professionals of the psychiatric institutions of the social sector and of mental health services units for childhood and adolescence to the Regional Coordination Team (ECR).

  • The coordination of the National Network of Long-Term Integrated Care is carried out at national level, without prejudice to regional and local coordination.

    The coordination of the network at the regional and local levels aims at its operationalization at these two territorial levels, ensuring its flexibility in the usage of the units and teams.