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

Individual GP practices 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…..

Current Medication / (Include strength and dose Name Co-Morbidities Current 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 AF Digoxin (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 2009 Bumetanide (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? yes Ivy 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 Type 2 diabetes mellitus (Review) History HbA1c level (DCCT aligned) 7.3 % Diabetic retinopathy (Review) Essential hypertension (Review) Obesity (Review) O/E - weight 250 kg Examination 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… 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