Long Term ConditionsCommunity Matrons

and the Respiratory Service:

‘a partnership in the making’

Julie MountainLynne WhiteAnne JonesVicky Walker

Aims of the session

• To highlight the development and progression ofTo highlight the development and progression of two key services within LTCtwo key services within LTC

• Emphasise positive impact on patient experienceEmphasise positive impact on patient experience byby

• Demonstrating how redesign of the services has Demonstrating how redesign of the services has lead to strengthening of the teamslead 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 workingClose 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 aYUV420 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 COPD and 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?

Lilly

Smoking Cessation

Pulmonary Rehabilitation

Supported EarlyDischarge

Breathe Easy

SocialLife

“I FeelFantastic”

COPD Self

Managementplan

Telehealth Communi

ty Matron

Refer to Respirat

ory Team

Personalised care plan

Medication Assessme

nt

Advanced clinical and

holistic assessments

Contacts

Julie Mountain: julie.mountain@nhs.net

Lynne White: lynne.white@nhs.net

Vicky Walker: vwalker@nhs.net

Anne Jones: anne.jones6@nhs.net