Clinics & services

High Risk Patient Programme (HRPP)

  • Description

    The High Risk Patient Programme (HRPP) is a way of working to join up care across the health and social care system. (Incorporates Frail Elderly Pathway and Integrated Care COPD programmes. HRPP aims to deliver excellent continuity and communication, less duplication and a patient-centred proactive approach, especially in managing our most vulnerable patients and/or those with long term conditions. It includes the population and management of a register, multidisciplinary team (MDT) reviews of these patients and assignment of a key worker to coordinate care.

  • Patient types/symptoms

    Patients on the practice high risk register include people with long term conditions and/or those at high risk of hospital admission or readmission

  • Location

    HRPP is delivered through multi disciplinary teams linked to individual GP practices in Northumberland and North Tyneside

  • Opening Times

    Patients are discussed/reviewed at multi disciplinary team (MDT)meetings.

Referral Information

For general enquiries email

Please see 'Useful forms' under High Risk Patient Programme for contacts for the programme by GP practice for pharmacy, social work, district nursing, geriatrician and respiratory nurse specialists.

Useful forms also includes
- HRPP screening tools
- COPD key worker pack
- HRPP case studies
- Copies of the latest newsletters
- Training flyers
- Presentations.

Patient films and a film describing the HRRP programme are available on You tube