Transcript Slide 1

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
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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
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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:
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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]