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.