Long Term Conditions
This presentation is the property of its rightful owner.
Sponsored Links
1 / 15

Julie Mountain Lynne White Anne Jones Vicky Walker PowerPoint PPT Presentation


  • 72 Views
  • Uploaded on
  • Presentation posted in: General

Long Term Conditions Community Matrons and the Respiratory Service: ‘a partnership in the making’. Julie Mountain Lynne White Anne Jones Vicky Walker. Aims of the session. To highlight the development and progression of two key services within LTC

Download Presentation

Julie Mountain Lynne White Anne Jones Vicky Walker

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Julie mountain lynne white anne jones vicky walker

Long Term ConditionsCommunity Matrons and the Respiratory Service:‘a partnership in the making’

Julie Mountain

Lynne White

Anne Jones

Vicky Walker


Julie mountain lynne white anne jones vicky walker

Aims of the session

  • To highlight the development and progression of

  • two key services within LTC

  • Emphasise positive impact on patient experience

  • by

  • Demonstrating how redesign of the services has

  • lead to strengthening of the teams


Julie mountain lynne white anne jones vicky walker

Community Matrons

  • 1.9 million investment

  • 44 matrons, 39 WTE

  • Leeds population over 803,000

  • Over 112,000 with LTC

  • Community Matron active case load approx 1800


Julie mountain lynne white anne jones vicky walker

“Community Matrons are likely to be popular with patients and increase access to care but they are unlikely to reduce hospital admissions unless there is also a more radical service redesign”

Gravelle et al. BMJ 2007


Julie mountain lynne white anne jones vicky walker

Overview of Community Matron Service in Leeds

  • From 5-1. Moving towards a city wide service (service review, 2007).

  • GP attached

  • University trained to advanced level

  • Caseload of 50 (dependent on complexity)

  • Age – adults, 18+

  • Community Geriatricians


Julie mountain lynne white anne jones vicky walker

Clinical Leads for Long Term Conditions

  • 2 recently appointed Clinical Leads for LTC’s

  • Promoting integrated working with other key services

  • Facilitating student placements

  • Active involvement and promotion of the clinical

  • professional engagement model

  • Supporting Community Matrons to develop and

  • advance in Community Matron roles incorporating

  • strong leadership component

  • Caseload analysis


Julie mountain lynne white anne jones vicky walker

The Road Ahead for LTC?

  • Integrated working

    • Close working relationships with specialist teams and all health and social care professionals

  • Achieving consistency in practice

  • Year of Care / personalised care plans

  • Shared documentation

  • Celebrating innovation


Julie mountain lynne white anne jones vicky walker

The Respiratory Service

  • 1 City wide team based on two site across the city (East and West)

  • From 3 teams to 1 since merger of PCT in Oct 2006

  • MDT highly specialist team, consisting of :

    • 14.12 WTE qualified - RNSs and Physiotherapists

    • 5.29 WTE clinical support workers

    • Admin.


Julie mountain lynne white anne jones vicky walker

On those with the disease

Progressive symptoms

Reduced exercise tolerance

Reduced quality of life

Loss of independence/confidence

Loss of self-esteem

On health and social services

Affects around 13000 people in Leeds

1/3 with significant disability and who have frequent GP consultations

Accounts for at least 10% of all admissions

Impact of Chronic Obstructive Pulmonary Disease (COPD)


Julie mountain lynne white anne jones vicky walker

What was the our response to this impact?

  • Listening to the needs of patients with COPDand their carers - Respiratory Roundtable

    • Care closer to home or at home;

  • Responsive and accessible services.

    • Wanted to feel more in control of their condition

  • “My Life Living with COPD - Putting The Living Back Into Life”

  • Discussions with other Health care professionals across the city

  • Considering the evidence – what was effective?


  • Julie mountain lynne white anne jones vicky walker

    The Community Respiratory Service

    Key components of the service:

    • Pulmonary Rehabilitation (PR)

    • Supported Early Discharge (SEDS)

    • Chronic disease management

    • Telemedicine

    • Review of patients on home oxygen

    • COPD education programme for staff

    • Patient Roundtable continues to inform development


    How we have helped

    How we have helped?

    Telehealth

    Community Matron

    COPD Self

    Management

    plan

    Medication Assessment

    Pulmonary

    Rehabilitation

    Smoking

    Cessation

    Lilly

    Advanced clinical and holistic assessments

    Breathe

    Easy

    Supported Early

    Discharge

    Personalised care plan

    Refer to Respiratory Team

    Social

    Life

    “I Feel

    Fantastic”


    Julie mountain lynne white anne jones vicky walker

    Contacts

    Julie Mountain: [email protected]

    Lynne White: [email protected]

    Vicky Walker: [email protected]

    Anne Jones: [email protected]


  • Login