Complex Care Sue Elvin Nurse Consultant District Nurse

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 Co-Morbidities Hypoventilation and nocturnal hypoxaemia Hypertension Date of Birth: 1949 AF CRT-D in situ 4. NIDDM NHS No: CKD- baseline creatinine 112 Schizophrenia Left mid cerebral infarct 2013; Right sided weakness Dilated cardiomyopathy EF 10 -20% Main Carers full name: (son) ECG: old LBBB Chronic type 2 respiratory failure. Mixed pathology, pulmonary and severe LVSD MI 2009 GP Name: Dr GP Practice: Current Medication / (Include strength and dose Problems For Discussion Ramipril (d) 5 mg PO ON recurrent admission Bisoprolol (d) 7. 5 mg PO OM concern regarding medication compliance- Reported by Digoxin (d) 125 micrograms ward staff pt tend to hide PO OM medications in her food Atorvastatin (d) 20 mg PO ON optimise hear failure; LV EF Glicazide (d) 160 mg PO BD 10 -15% Metformin (d) 500 mg PO BD Spironolactone (d) 50 mg PO OM has home NIV - ? compliance Rivaroxiban (d) 20 mg PO 18 pm Ivabradine (d) 5 mg PO BD Bumetanide (d) 3 mg PO OM Bumetanide (d) 2 mg PO 14 pm Flupenthixol 60 mg IM every 3 weeks Continue Continuing next due 01/04/2015 Senna 7. 5 mg PO BD PRN Has this patient given their consent to view the GP Abbey Medical Centre records? 85 Abbey Rd NW 8 0 AG verbal consent yes 14/4/15 Presented by: Does this patient have capacity sufficient to make decisions around own care? Ivy Macalino RFH-Resp 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 History Problem History Examination Problem History 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. Case conference XXXXX Venous ulcer of leg (Review) Laterality: Bilateral Type 2 diabetes mellitus (Review) Hb. A 1 c level (DCCT aligned) 7. 3 % Diabetic retinopathy (Review) Essential hypertension (Review) Obesity (Review) O/E - weight 250 kg Body mass index 73 kg/m 2 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. 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 Time per Minutes 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 2 hrs 45 mins £ 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