Table 1 Community based chronic disease services
Complex needs case management model | Respiratory service | Neurological service | Diabetes service |
|---|---|---|---|
Site A | Site A | Site A | Site A |
Community Matron model. | Led by respiratory nurse consultant with a team of nurse specialists, physiotherapists, and administration support. | Team of nurses and therapists. | Managed by a nurse consultant under a single budget with a number of diabetes nurse specialists. |
Model adapted from United Health. | Medical consultant input though local and neighbouring acute hospitals. | Work with patients from diagnosis to end of life. | Provides community based clinics, education for GPs and practice nurses, structured self-management education. |
Co-located with intermediate care teams. | Â | Patients refer themselves in and out of the service as required. | Â |
Loosely attached to GP practices. | Â | Â | Â |
Site B | Site B | Site B | Site B |
Integrated Community Team. | Covers all respiratory diseases and oxygen reviews. | 3 specialist nurses. | 1 diabetes nurse specialist and 1 Diabetes Practitioner Consultant. |
One team per the three PCT localities. | Â | 22 bedded stroke and neurology rehabilitation unit. | Structured self-management programme is provided |
Teams include community matron (case manager), district nurses, and therapists. | Led by a respiratory nurse consultant and team of nurse specialists and a physiotherapist. | Â | Diabetes Nurse Specialist runs clinics in 2 GP centres. |
Community matron & district nurses also attached to GP surgeries. | Provide pulmonary rehabilitation. | Â | Â |