Complex Care

Sue ElvinNurse Consultant District Nurse

• 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

Who are we?

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 Co-MorbiditiesCurrent Medication / (Include

strength and dose Problems For Discussion

 Hypoventilation and nocturnal hypoxaemia Ramipril (d) 5mg PO ON recurrent admission

  Hypertension Bisoprolol (d) 7.5mg PO OM  

Date of Birth: 1949 AFDigoxin (d) 125 micrograms PO OM

concern regarding medication compliance- Reported by ward staff pt tend to hide medications in her food

  CRT-D in situ4. NIDDM Atorvastatin (d) 20mg PO ON  

  CKD- baseline creatinine 112 Glicazide (d) 160mg PO BD optimise hear failure; LV EF 10-15%

NHS No: Schizophrenia Metformin (d) 500mg PO BD  

  Left mid cerebral infarct 2013; Right sided weakness

Spironolactone (d) 50mg PO OM has home NIV - ?compliance

  Dilated cardiomyopathy EF 10-20%

Rivaroxiban (d) 20mg PO 18pm  

Main Carers full name: ECG: old LBBB Ivabradine (d) 5mg PO BD  

(son)

Chronic type 2 respiratory failure. Mixed pathology, pulmonary and severe LVSD Bumetanide (d) 3mg PO OM  

  MI 2009Bumetanide (d) 2mg PO 14pm

GP Name:  

Flupenthixol 60mg IM every 3 weeks Continue Continuing next due 01/04/2015

Dr   Senna 7.5mg PO BD PRN       GP Practice:      

Abbey Medical Centre

Has this patient given their consent to view the GP records?      

85 Abbey Rd NW8 0AG verbal consent yes 14/4/15      Presented by: Does this patient have capacity sufficient to make decisions around own care? yesIvy Macalino      RFH-Resp             

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   Case conference XXXXX Problem   Venous ulcer of leg (Review) Laterality: Bilateral Problem   Type 2 diabetes mellitus (Review) History   HbA1c level (DCCT aligned) 7.3 % Problem   Diabetic retinopathy (Review) Problem   Essential hypertension (Review) Problem   Obesity (Review) History   O/E - weight 250 kg Examination   Body mass index 73 kg/m2 Problem   Breathlessness (Review) History   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…

• 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 per week

Time per visit

Minutes per week

Cost of dressings

Cost of compression

Total

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

s.elvin@nhs.net