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