Caring for long-term & chronic conditions

once unable to access surgery, patients will receive timely care

The Long Term Health Conditions team runs alongside the community nursing service for all patients registered within Freshney Pelham Federation practices.


The service manages patients with 1 or more chronic or long-term condition across their illness trajectory. The patient whilst able will continue to visit the practices for management of their condition by G.P or Practice Nurse. During this time the patient will also be known by the long-term condition team manager and any episodes of acute exacerbation and the patient being housebound, the L.T.C Team manager would assess and manage acute episode of care.

The aim of this service is to ensure the patient once unable to access the surgery will receive timely care and effective collaboration with all professionals will be provided. Avoidable hospital admissions will be paramount. 

The community nursing Long Term Health Conditions Team manages the patient once housebound, ensuring that all professionals in the practices are aware of the trajectory and management plans are discussed at weekly multi-disciplinary meetings.  Once the patient is receiving end of life care the community nursing team will be able to support this pathway and provide effective support and symptom management.

Contact our Long Term Care Team

Our Long Term Health Conditions Team is on hand to help with your loved ones love term care needs – contact us to see how we can help.

fpc.enquiries@nhs.net
Freshney Green Primary Care Centre, Sorrel Road, Grimsby, DN34 4GB

Our long term care team

Sally Kolberg

Long Term Condition Team Manager
Recently appointed as the Long Term Condition Manager, with many years working as a Practice Nurse for the Fieldhouse Practice.

Ellie Clarke

Team Leader
My name is Ellie Clarke. I am the long term conditions team leader. I have 18 years’ experience working as community staff nurse, senior nurse in the Haven Team and finally working with complex health and social needs with patients with a long term condition, preventing any unnecessary hospital admissions. My passion is palliative and end of life care.

Joanne Dean

Senior Staff Nurse
I have been a registered nurse for almost ten years and have worked within both hospital and community settings. I have worked for FPC for just over 2 years and I am currently working as a community nurse within the Long Term Conditions team. I am enjoying this role and am undertaking a module in Supporting Adults with Long Term Conditions at the University of Hull.

Digna Thompson

Assistant Practitioner

Lisa Morris

Assistant Practitioner
I have just become an AP at Freshney Pelham Care. My current role within the Long Term Condition Team and District nursing team includes, woundcare, administering insulin, completing assessment’s including Elderly health and COPD