Download Cluster Service Model There are 16 Cluster service arrangements

Cluster Service Model
There are 16 Cluster service arrangements across Devon with 23
Complex Care Teams, based around GP practice populations
The Health and Social Care Cluster Manager is the line manager that
brings all of these factors together into a coherent operational model.
The attached diagram illustrates the context in which Complex Care
Teams will operate within their Health and Social care cluster areas.
The central CCT section indicates the core activity of complex care
teams: case management for very high intensity users. As such, the
community matron role rests entirely within this section.
Other aspects of community nursing, therapy, primary care, social care,
OPMH services and community hospitals will all have a vital part to play
in the delivery of care to this group of patients. They may deliver a full
case management function, or offer specialist interventions to people
receiving case management.
The darker blue circle indicates that each of these groups of staff and
services also deliver interventions to people who have lower level needs
and represents those single service, time limited interventions with more
predictable outcomes or specialist services provided within hospital or
primary care settings.
Case studies are also provided as examples of the benefits of an integrated
approach to the patient.
Cluster Service Model
Community
Nursing
Primary
Care
Practices
Practice
Manager
Voluntary
sector
organisations
Voluntary
sector coordinator
Community
Nurse
Team
Manager
GP
Practice/s
Community
Nurse Team
Leader
OPMH
health
services
ACS
Practice
Manager
Social work
OT’s
Community
Care work
Modern
Matron
Therapy
Manager
Therapy
services
Community
Hospital
Case studies showing the benefits of an integrated approach to the patient.
Complex Care Teams Case Study 1 – Exeter B
Updated 8th July 2008
This document represents a summary of the last months in the life of a widowed 87 year old man with
carcinoma of the oesophagus and COPD. Mr JH was extremely assertive in his determination to
control the circumstances of his own decline and death. He had nursed his wife for nine years following
a stroke which left her without speech.
Presentation
Mr JH was referred to the community matron at the end of September 2006. He had a high PARR
score on referral and was known to be ‘difficult’. He had a stent in situ and was expected to die within
six months. He lived alone in his clean and tidy home which was where he wanted to die. Close to
being bed bound, he had a low haemoglobin, although a transfusion was not indicated. He was losing
weight and Ensure food supplements were his only nutrition. He had chronic constipation but refused
conventional treatment for this.
Mr JH was an intelligent, highly articulate man; a member of MENSA whose main interest was opera.
He was extremely knowledgeable and insightful about his condition but also obstructive and very
cynical. His resistance to conventional health and social care management had been vehement and
sustained. At the time of referral, he had had three Hospiscare nurses. A vital factor in his care was the
ability to secure his respect and confidence.
Team Approach and Interventions
The community matron began one hour weekly visits and his GP visited weekly at a different time. The
OT care manager acted upon the community matron’s advice and visited when indicated. The key input
from the community matron was psychological support; in order to gain his confidence and to
encourage his will to live. She liaised closely with his GP. Mr JH continued to fiercely defend his
ownership of his condition and situation.
For the last month of his life Mr JH was bed bound and extremely weak and taking only water. He was
symptomatically well controlled. The plan was to provide adequate support for Mr JH to die at home.
He had a package of care which comprised of Marie Curie nurses, rapid response team, Care Plus
Agency, community matron, district nurses, Hospiscare Nurse and GP. He died at home on 27th March
2007. Rapid response and the community matron were present. It was a serene end to a difficult
illness.
Evaluation
Mr JH’s desire to die in his own home, where there were no relatives to support him, involved
considerable challenges and risks. This objective could not have been achieved without the effective
care and communication of the whole complex care team. Each member had a valuable and essential
role to play. The case is a powerful example of how individualised quality of life and death can be
upheld by a team approach to complex care, even in the most demanding of situations.
Prior to his death Mr JH wrote an account of his experiences and this was used by the community
matron in a conference presentation. Below is a short extract:The local medical practice was recently fortunate enough to add to its ranks a community
matron and I found that I qualified for a weekly visit……. I am well aware that my diseases are
incurable and I do not look for cures……….. Apart from taking an interest in my medication and
ensuring that I take it, there is not much that [the community matron] can do in a practical way
to ease my discomfort. Well, what else is there? [The community matron] is generous with her
time and I look forward to her visits. It is stimulating to spend a little time with an intelligent and
articulate person. From the moment of her arrival she radiates enthusiasm for her task and I
am always conscious of her general interest in me. She listens attentively to what I have to say
and I listen with equal care to her advice.
Above all and far more important than the professional relationship between nurse and patient,
is the need to establish friendship; which I define as never having to say sorry. In other words
friends can say anything to each other. I have met a good many doctors and nurses who are
conspicuous because of their brisk, business-like efficiency. And more often than not they
cannot even muster a smile. Something more is needed from those who deal with the
terminally ill. Some weeks ago in connection with another unpleasant illness, my doctor
invoked the aid of the rapid response team. For their benefit the district nurse wrote “Make JH
feel cared for”. I have explained how [the community matron] does that. When she has left
there is an afterglow that lasts throughout the day.
Complex Care Teams
Case Study 2 – Exeter A
Updated 19th June 2008
This document describes a synopsis of care for a 75 year old gentleman who lives in sheltered
accommodation in a rural location. His principal diagnosis is progressive bulbar palsy, motor neurone
disease. Immediately prior to referral he had suffered a bereavement of his close friend and neighbour
for whom he was a carer.
Presentation
Upon referral he was isolated due to his rural location and the death of his close friend. His motor
neurone disease causes hyper-salivation and communication barriers. He has a PEG for nutrition and
also has compromised respiratory muscle function. He was unable to access the bath and the ordering
and collection of medications was problematic.
Impending refurbishment works at his home required a temporary placement elsewhere. His care was
complicated by the involvement of a range of professionals whose input and communication was
uncoordinated and fragmented
Team approach and interventions
An occupational therapy assessment was carried out and some minor adaptations including a key box
and the installation of a level access shower were made. He required respite care during these
alterations. Later a riser-recliner chair was obtained on loan from the Motor Neurone Disease
Association (MNDA). The patient was referred to the Hospice where he now attends weekly day care
sessions and he was an inpatient there over the Christmas period.
He has regular contact with the community matron and the community dietician who monitors his PEG
and nutrition. Following an assessment by the speech and language therapist he was provided with a
litewriter. He was assessed by the respiratory specialist physiotherapist and suction was made
available. Since then he has had successful surgery to control his hyper-salivation. He now has a
nebuliser and a catheter.
His benefits were reviewed and a care package was commenced which has been increased recently to
twice a day. The domiciliary pharmacist intervened to facilitate his medication ordering and delivery.
Links have been established with the MNDA and a voluntary visitor calls on him. In view of the
complexity of his medical equipment, a private ambulance has been organised which will transport him
when he needs to move into respite care. The Out of Hours service has been informed of this patient’s
situation and any changes that occur.
Evaluation
There is a continuing team approach to ongoing rehabilitation and health needs with a weekly visit by
the community matron to assess, implement and evaluate care needs. This has resulted in appropriate
and timely interventions to manage the stages of his disease process. A management plan was
completed to acknowledge the risk of aspiration. The appropriate levels of care and support have meant
that he has been able to remain at home, even though he lives alone and cannot speak. His feelings of
isolation have been reduced and his dignity and choices upheld. He has enjoyed a successful stay in
Vanbrough, an intermediate care setting, and this has been arranged for any further placements in
event of his decline.
He is able to write and has stated:My Community Matron and Occupational Therapist have kept me living [here] as I don’t want to
be put into a rest home, as yet. I live in my own home and they organise care and visit me once
a week, making sure all my machines are working. As I can’t speak, I find it very difficult to use
[the] phone and they understand me. I go to Hospiscare once a week where I reach friends.