Case Management Long Term Conditions
Providing case management and advanced clinical skills to patients with one or more long term condition that have or would have become Very High Intensity Users (VHIU’s) of primary or secondary care health services without the intervention of case managers/community matrons.
This service is specifically designed to:
- Maximise independence
- Prevent inappropriate hospital admissions
- Assist prompt transfers of care from acute to community settings
- Provide palliative/terminal care for patients whose preference it is to be cared for at home
- Achieve optimum treatment/intervention outcomes
Where service is based
In patient’s homes, including residential care settings.
Community clinics: Thundersley Clinic.
Primary Care Centres (PCC): Leigh PCC, Canvey PCC.
Hours of operation
365 days/year 08.30 to 17.00
Telephone calls taken out of hours by District Nurse Service.
How to contact service
Patients: 01702 608250 (District Nurse Liaison)
How to refer into the service & who can refer
Any health care professional can refer into the service. If a patient wishes to make a self- referral, they should contact their GP, who can refer on their behalf.