A nurse led team. Supports people to self-manage their long term conditions, multimorbidity and frailty. Focus is on supported self-management of mainly respiratory and cardiac disease. Helps people, as well as their carers and families, to recognise signs and symptoms of their health getting worse.
Uses customised care planning to empower people to react in good time and escalate concerns appropriately. In so doing so, help people avoid unnecessary hospitalisation. Focus on person centredness and promoting future care planning as a matter of priority.
