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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 • 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 QuickTime™ and a YUV420 codec decompressor are needed to see this picture. 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. Impact of Chronic Obstructive Pulmonary Disease (COPD) – 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 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? Telehealth Community Matron COPD Self Management plan Medication Assessmen t Pulmonary Rehabilitation Smoking Cessation Lilly Advanced clinical and holistic assessments Supported Early Discharge Personalised care plan “I Feel Fantastic” Refer to Respirator y Team Contacts Julie Mountain: [email protected] Lynne White: [email protected] Vicky Walker: [email protected] Anne Jones: [email protected]