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Contact details
Telephone 0114 3054280
0114 3054281

 

Fax 0114 271 6293
0114 271 6333

Service lead
Janine Thornton
Community Services General Manager
Long Term Conditions Clinical Business Unit
janine.thornton@nhs.net
Telephone 0114 3051446

Location/s for Service Delivery
Citywide

Operating Hours
08.30 – 17.00 Monday to Friday

Pro-active Case management of long term conditions at level 3

Patient assessment can take place in:

• Patients home
• Residential Care
• Specialist residential care
• Acute setting

Patient referral Criteria
Has 2 or more diagnosed long term conditions (see examples) which have been ongoing for 12 or more months
• Have had 2 or more unplanned admissions to hospital within the past 12 months
• Long term conditions severely restrict access to health care
• Are taking 5 or more prescribed medications
• 18 years and over

Long Term Condition (examples)

  • COPD
  • Diabetes
  • Heart Failure
  • CVD
  • Multiple sclerosis
  • Motor Neurone disease
  • Parkinsons Disease
  • Arthritis

Please note that the criteria is flexible, individuals with complex long term conditions may not meet all the requirements but will be considered following an assessment from the community matron

Referrals Referrals into the service are via Single Point of Access (SPA).

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