Trafford Case Management

Trafford Case Management provides wraparound care at home or in the community for patients with a chronic long-term health condition that would get worse without expert support. 

Our aim is to keep patients well in the community. We work with the patient to set goals and work with them over a three-month time frame. The aim is to improve their self-care and knowledge so their condition can be managed.

We help anyone registered with a Trafford GP who is over the age of 18 and has a chronic long-term health condition that cold get worse without support.

That might be heart failure, a chronic respiratory (breathing/lung) condition or another condition that requires help to manage – where the patient is not already under the care of a specialist nurse for their condition.

Our team of highly skilled nurses work with the patient and set an individual plan based on their needs.

We will set patient-oriented goals to help them manage their condition and work with the patient to reach these goals within a three-month time frame.

As part of that work with the patient we will:

  • Help prevent the need for hospital admission by improving self-care and increasing the patient’s knowledge of how to manage their condition
  • Make things as easy as possible for patients who have complex needs because of their condition to navigate the different health and care services that they might need to use
  • Identify any needs for other services like social prescribing (community based non-medical support for people), community therapy and other support – and make referrals on behalf of the patient
  • Work with the patient on education for their condition and other health issues they might have so they have the skills and knowledge they need to better care for themselves over time. We might link in with other services to do this (for example we have a Diabetes project working with the District Nursing team).

Our service is available from 8am to 4pm, Monday to Friday. If you are being cared for by the team and have any questions, you can contact us via the number the team have provided you with.

If you are calling outside of our service hours for non-emergency advice please contact NHS 111 or your GP Surgery in the first instance. In case of an emergency please contact 111 or 999 for immediate advice or support.

Referrals are accepted from all health care professionals, including GPs, secondary care and Community Health Services.

To refer, complete the referral form below and email it to

Alternatively, if you wish to talk to the team about a patient, please ring 0300 323 0303 (option 1) and ask for Case Management. Leave a message with the call handler and we will call you back. For general queries to the service email

Referral inclusion criteria

  • Patients must be registered with a Trafford GP
  • Patients must have a chronic long term health condition of heart failure / chronic respiratory or a condition that requires help to manage and who are not already under the care of a specialist nurse for their condition
  • Patients must be at risk of deterioration without the input of the service
  • Patients must be over 18 years old.

Referral exclusion criteria

  • Patients under 18 years of age
  • Patients who are pregnant
  • Patients who are receiving end of life care
  • Mental health or alcohol or drug abuse cannot be the presenting condition
  • Patients in a nursing home
  • Patients who are already under specialist nursing for the referring condition
  • Acutely unwell patients (if urgent same day input needed for acutely unwell patients, contact the Community Crisis Response Team).

Page last reviewed: December 2023
Next review due: December 2024