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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

  • 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

  • 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?

  • 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

  • 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

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?

  • 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

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?


Community Matron




Medication Assessment






Advanced clinical and holistic assessments



Supported Early


Personalised care plan

Refer to Respiratory Team



“I Feel




Julie Mountain:

Lynne White:

Vicky Walker:

Anne Jones: