Transcript Case Management

Complex Care
Sue Elvin
Nurse Consultant District Nurse
Who are we?
• 3 dedicated Complex Care Nurses & 1
dedicated CPN Complex Care Nurse
• Based in IPC DN Teams, North in Gospel
Oak, South in Hunter Street, West in
Belsize Priory
• NC work across whole of Camden,
support and discreet caseload, clinically
supervise complex care nurses
• Avenue/fast track to teams and services
provided by CNWL Camden Provider
services
Referrals
• Directly from MDT Hub
• Individual GP practices
• Complex patients from within existing DN
caseload or newly referred in to the service
screened as having complex needs
How to refer
• GP complex care meetings• Via Hub MDT
Example of referral next slide…..
Name
Date of Birth: 1949
NHS No:
Main Carers full
name:
(son)
Co-Morbidities
Hypoventilation and nocturnal
hypoxaemia
Hypertension
Current Medication / (Include
strength and dose
Ramipril (d) 5mg PO ON
Bisoprolol (d) 7.5mg PO OM
Problems For Discussion
recurrent admission
concern regarding medication
compliance- Reported by
ward staff pt tend to hide
medications in her food
AF
CRT-D in situ4. NIDDM
Digoxin (d) 125 micrograms
PO OM
Atorvastatin (d) 20mg PO ON
CKD- baseline creatinine 112
Schizophrenia
Left mid cerebral infarct
2013; Right sided weakness
Dilated cardiomyopathy EF
10-20%
optimise hear failure; LV EF
Glicazide (d) 160mg PO BD 10-15%
Metformin (d) 500mg PO BD
Spironolactone (d) 50mg PO
OM
has home NIV - ?compliance
Rivaroxiban (d) 20mg PO
18pm
ECG: old LBBB
Chronic type 2 respiratory
failure. Mixed pathology,
pulmonary and severe LVSD
MI 2009
GP Name:
Dr
Ivabradine (d) 5mg PO BD
Bumetanide (d) 3mg PO OM
Bumetanide (d) 2mg PO
14pm
Flupenthixol 60mg IM every 3
weeks Continue Continuing
next due 01/04/2015
Senna 7.5mg PO BD PRN
GP Practice:
Abbey Medical
Centre
85 Abbey Rd NW8
0AG
Presented by:
Ivy Macalino
RFH-Resp
Has this patient given their
consent to view the GP
records?
verbal consent yes 14/4/15
Does this patient have capacity sufficient to make decisions around own care?
yes
Benefits of MDT working
•
•
•
•
Networks
Communication
Key heads together
Shared local intelligence knowledge of
patients, services
• Highlighting of what works
• Identification of gaps in service
• Holistic overview of patients & ability to
gain consensus re best plan & best placed
people/services
Case study patient D
28-May-2014
Problem
Problem
History
Problem
Problem
Problem
History
Examination
Problem
History
Case conference XXXXX
Venous ulcer of leg (Review) Laterality: Bilateral
Type 2 diabetes mellitus (Review)
HbA1c level (DCCT aligned) 7.3 %
Diabetic retinopathy (Review)
Essential hypertension (Review)
Obesity (Review)
O/E - weight 250 kg
Body mass index 73 kg/m2
Breathlessness (Review)
Presented by XXXX, community nurse.
Has been referred to Hub as concerns about type 2 diabetes, obesity,
breathlessness, low mood and housebound. GP is a fair distance away
now as moved recently. Unable to register with new GP.
Swollen legs - was referred to the lymphoedema clinic in ULCH and
advised to refer to River Place which has been done. Note on
amlodipine which can worsen leg oedema.
Very breathless on minimal exertion. Discussed possibility of OSA.
Also isolated and now not going out as has previously been verbally
abused by passersby.
Medication - note review by diabetes team recently suggested using
sitagliptin (not currently prescribed) - and gliclazide might worse obesity.
Medication - prescribed aspirin and hydroxyzine, not clear of
indications.

XXX and XXX will arrange joint visit. To perform Epworth sleepiness
score.

XXX, social worker, will review patient.

GP - please could you arrange bloods including FBC, BNP, U & E,
LFTs - probably also worth urine dipstick too.

GP - please consider stopping amlodipine (leg swelling), and review
indications for aspirin and hydroxyzine. Also you might wish to
prescribe sitagliptin.

Consider referral for OSA depending on Epworth score.

Hub will review in 3 weeks.
Services involved
• CNWL DN service
• CNWL NC , Hub SW, carers from care
agency
• CNWL TVN
• GP
• Acute admission (nightmare!)
• ASC OT
• CNWL Psychologist
• CNWL Diabetic podiatry
Services involved cont…
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CNWL Phlebotomy
Diabetes Team UCLH & CCG Project
CCG Commissioning
Support with new lymphoedema garment
& UCS Wipes
• Bariatric Team Imperial
• Student SW
Benefits to our involvement
• Patient describes his life as “turned
around”
• Ability to self care and manage and take
control of his life
• Erected a mirror in his house-shaved,
looking good
• New dressing regime-pilot-see cost
savings
Cost savings from new
compression & cleansing pilot
Visits
Time per Minutes Cost of
Cost of
Total
per week visit
per week dressing compres
s
sion
Was
3+
85
255
£103.38
£126.68
£230.07
Now
2
45
90
£8.48
£13.07
£21.55
Saving
1
Time
2hrs
45mins
£94.90
£113.61
£208.51
The above shows a weekly cost saving for this patient, total saving for 6
months is £5,421.26
Benefits to our involvement
• Diabetic foot ulcers healed
• Leg ulcers healed
• New dry mattress and bed-no more
leaking!
• Accepted for bariatric surgery including
panniculectomy
• Accepted for full Lymphoedema
assessment TXT
Benefits to our involvement
• A chair that fits!
• Hope for the future…….
Consider the alternative if we’d
not got involved
• An early miserable death
• Potential to become bed bound and totally
dependent on services
Thank you
• Please keep referring-increase referrals
[email protected]