Title: Complex Care Nurse Specialist Role Dr Lorna Dunlop
1Complex Care Nurse Specialist RoleDr Lorna
Dunlop
- Managing co-mobidity
- Delivering Patient Centred Scheduled Care
efficiently by managing the Primary Care Team
2Comorbidity(the simultaneous presence of
multiple chronic conditions)
3Co-prevalence
4Managing co-morbidity
- Co-morbidity varies with each diagnosis
- use of resources depends on the degree of
co-morbidity (co-prevalance) rather than the
diagnosis - 1222/5000 on recall management (lt25)
- 650/5000 patient UE checked lt1y
- No new patients with CKD
- Additional monitoring in patient subgroup
patient centred care.
5Code Items of a Care Plan
6Clinical Care Follow Up Plan
- Maps the patient journey items of care
- Explains the patient journey comments on care
- Team members responsible for care
- Hands over responsibility to the patient
- Safety nets the deal with a further plan sent by
post should the patient default (plan may be
altered with revised care efficiencies) - Date of issue any freetext patient note ? Read
coded in primary care system
7Clinical Care Follow Up Plan- upper page
8Clinical Care Follow Up Plan- lower page
9Clinical Care Follow Up Plans
- Patient centred care reducing duplication
- Workforce planning
- Failsafe tracking of patient care automatic
10Dynamic Care Strategy
- Patient Care Plan interacts dynamically with the
scheduling system - Complex Care Nurse specialist role reviews a
daily report for missed deadlines and
proactively manages patients who default -
partial attenders can be advised
11Missed Deadlines Report
12Complex Care Nurse Specialist Tasks
- Creates new electronic patient management plans
protocols, tasks, condition reviews devises
team care - Trains updates staff how to use recall system
- checks missed deadlines report daily (results not
back recalls DN) advises health care
assistant or admin staff which recalls can be
sent by them checks care plan details appts of
others reassessing clinical need. - Defining and controlling practice resources
13Complex Care Nurse Specialist Benefits
- Delivers chronic disease management at a higher
skill level /- prescribing, maximising own
skills - Job satisfaction as work is not task
orientated, looking at whole patient care - Training HCA (course recommendations eg wound
dressing, spirometry) and FY2 (chronic disease
management) increasing skills of team
14Nurse patient relationship
- Education of patient leads to increasing
interest in own care - Maintains or upgrades level of patient health
confidence - Trust patient feels that they are not forgotten
15Benefit to patient
- Understanding of what is expected of them
- Negotiation of any change and priorities
- Working patients can be seen at a time that suits
them and have tasks carried out by HCA clinical
reviews by nurse. Saves money (fares) and time
(work) for patient.
16WORKING TOGETHERComplex Care Nurse Specialist
Role in scheduled primary care