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.