1. Complex Care Sue Elvin Nurse Consultant District Nurse

2. 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

3. 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

4. How to refer GP complex care meetings- Via Hub MDT
Example of referral next slide…..

5. 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

6. 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

7. Case study patient D

8. 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.

9. 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.

10. 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

11. Services involved cont…
CNWL Phlebotomy
Diabetes Team UCLH & CCG Project
CCG Commissioning
Support with new lymphoedema garment & UCS Wipes
Bariatric Team Imperial
Student SW

12. 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

13. 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

14. 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

15. Benefits to our involvement
A chair that fits!
Hope for the future…….

16. Consider the alternative if we’d not got involved
An early miserable death
Potential to become bed bound and totally dependent on services

17. Thank you
Please keep referring-increase referrals