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Long Term Conditions - Community Matron

The Long Term Conditions (LTC) team is a city-wide service, based in localities, with each GP surgery having representation from the team.

The Long Term Conditions team co-ordinates holistic care for people with complex health needs, working closely with other agencies to promote quality of life, independence as far as possible, and to empower people to make informed decisions about their lives.

The team aims to reduce hospital admissions and the length of stay in hospital, supporting people in their preferred place of care regularly and more intensively during periods of crisis.

City-wide referrals are received from anyone via a single point of referral and are considered against the referral criteria. Telephone (01752) 434629.

For contact details of the Long Term Conditions team in your Locality, you can contact your GP surgery or any professional working within Livewell Southwest.

 

Pictured below: Penelope - one of Livewell Southwest's Community Matrons.

 

 

 

 

 

 

 

 

 

 

 

 

Long Term Condition Community Matron Aims:

  • To actively identify patients who may benefit from case management.
  • To provide and facilitate the co-ordination of individualised holistic care for people with multiple co-morbidities who are very high intensity service users
  • To undertake advanced clinical assessments of patients
  • To educate patients/families/carers promoting effective self-management
  • To intervene in crisis situations, diagnosing and providing/organising treatment/s at home.
  • To prevent unnecessary GP and Ambulance call outs and hospital admissions
  • To liaise with secondary care to facilitate early discharge of patients on the Community Matron case load
  • To apply advanced clinical and leadership skills to ensure that the most appropriate care and support are delivered at all times

 

Guidelines for Referral to Community Matron for Complex Case Management

  • Must be over 18 years old
  • Must have at least one active Long Term Condition, which is unstable, so must show evidence of this with at least 3 of the following criteria:

- More than 3 unplanned admissions / non-conveyed calls in past year
- Frequent / increased contact with GP or other healthcare professional causing concern
- Poly-pharmacy and concerns regarding compliance / ability to manage medicines and / or side effects
- More than 2 falls in past year
- Increased social care needs and package failing to maintain stability
- Identified on risk stratification tool as High Risk / Very High Risk / High climber
- Confusion / memory loss

  • Patient must have given consent / agree with referral and be willing to engage with the service
  • Must be an achievable goal / reason for referral. Examples include:

- Improve quality of life
- Reduce inappropriate admissions
- Improve medicines management
- Provide crisis management which will enable patient to remain at home
- Reduced GP contacts and improved MDT care


 

Contact

City-wide central referral hub
Tel: 01752 434629
Jules Buck - Complex Care Team Coordinator

 

Community Matrons - North Locality
Sandy Gidley & Emma Pearson 
Tel: 01752 434548
 

Community Matrons - East Locality
Helen Fisher & Lorna Sutton
Tel: 01752 434155
 

Community Matrons - South Locality
Kirsty Settle, Faye Chinn & Louise Mackenzie
Tel: 01752 434331
 

Community Matrons - West Locality
Penelope Andrews, Jane Dart & Trudi Jones
Tel: 01752 434627

 

No out of hours service - Devon Doctors to be contacted for GPs, or District Nurse service for support.

Condition Information Links