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.
Customised care planning is used to empower people to react in good time and escalate concerns appropriately. In doing so this will help people avoid unnecessary hospitalisations, focussing on a persons centredness and promoting future care planning as a priority.
