Long Term Conditions Team
The long term conditions team provide support for people with complex long term conditions. The team is made up of Case Managers and Community Matrons.
Case Managers are social workers, community matrons or nurses who work with individuals who have complex multiple long term conditions and intense needs and whose care requires coordination.
The team provides a full case management service for patients who are very high intensity users of secondary care services.
With support from the long term conditions team, patients are able to remain in
the home for longer, having more choice about their future. By using the case
management approach, the team can:
- combine high level assessment of physical, mental and social care needs
- review medication
- provide clinical care and health promoting interventions
- co-ordinate inputs from other agencies
- teach and educate patients and their carers regarding complications or crisis
- enable patients to make choices about their needs
The benefits to case management are:
- helps to prevent unnecessary admissions to hospital
- reduces length of stay of necessary hospital admissions
- improves outcomes for patients
- integrates all elements of care
- improves quality of life for patients
- helps patients and their families plan for the future
- increases choice for patients
- enables patients to remain in their homes and communities
- improves end of life care
