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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

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Long Term ConditionsCommunity 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

  • Emphasise positive impact on patient experience

  • by

  • Demonstrating how redesign of the services has

  • lead to strengthening of the teams


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


“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


Overview of Community Matron Service in Leeds and increase access to care but they are unlikely to reduce hospital admissions unless there is also a more radical service redesign”

  • 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


Clinical Leads for Long Term Conditions and increase access to care but they are unlikely to reduce hospital admissions unless there is also a more radical service redesign”

  • 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


The Road Ahead for LTC? and increase access to care but they are unlikely to reduce hospital admissions unless there is also a more radical service redesign”

  • 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


The Respiratory Service and increase access to care but they are unlikely to reduce hospital admissions unless there is also a more radical service redesign”

  • 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.


On those with the disease and increase access to care but they are unlikely to reduce hospital admissions unless there is also a more radical service redesign”

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)


What was the our response to this impact? and increase access to care but they are unlikely to reduce hospital admissions unless there is also a more radical service redesign”

  • 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?


  • The Community Respiratory Service and increase access to care but they are unlikely to reduce hospital admissions unless there is also a more radical service redesign”

    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? and increase access to care but they are unlikely to reduce hospital admissions unless there is also a more radical service redesign”

    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”


    Contacts and increase access to care but they are unlikely to reduce hospital admissions unless there is also a more radical service redesign”

    Julie Mountain: [email protected]

    Lynne White: [email protected]

    Vicky Walker: [email protected]

    Anne Jones: [email protected]


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