Complex Care Nurse Specialist Role Dr Lorna Dunlop

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Complex Care Nurse Specialist RoleDr Lorna
Dunlop

• Managing co-mobidity
• Delivering Patient Centred Scheduled Care
  efficiently by managing the Primary Care Team

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Comorbidity(the simultaneous presence of
multiple chronic conditions)
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Co-prevalence
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Managing 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.

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Code Items of a Care Plan
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Clinical 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

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Clinical Care Follow Up Plan- upper page
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Clinical Care Follow Up Plan- lower page
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Clinical Care Follow Up Plans

• Patient centred care reducing duplication
• Workforce planning
• Failsafe tracking of patient care automatic

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Dynamic 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

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Missed Deadlines Report
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Complex 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

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Complex 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

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Nurse 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

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Benefit 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.

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WORKING TOGETHERComplex Care Nurse Specialist
Role in scheduled primary care