Second Street Surgery

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Complex Care Team

Our small team of clinical staff aim to help people avoid hospital by providing a variety of both clinical and social input. This constitutes part of our broader practice nursing team, within which new roles have been developed to meet patient need.

The team use the year of care approach (care planning) to manage long term conditions, an approach that is used by the Complex Care Team for management of housebound patients with two or more long term conditions.

We accept referrals from anyone who may have concerns that a person may be becoming frail, less independent, or relying much more on family support. We also provide assistance for patients who are finding they have to have increased GP support or attend hospital A&E more often. We are not an urgent response team and so it is always better to inform the team if concerns need to be addressed more timely.

If you require further information please contact the practice.

Julie Bray – Complex Care Team Lead

Julie has a clinical background which enables to identify any concerns in patient care. Julie’s role is to coordinate patients care to the appropriate member of the Complex Care Team and GP’s ensuring they are on the correct patient care pathway.  A weekly Multidisciplinary Team Meeting is held with the Team and Lead GP to discuss any concerns and case findings. Julie also works alongside the voluntary sector, networks, organisations and secondary care collaborating, supporting and strengthening  services in  our local community . Julie also supports Severe Mental Illness and Weight Management services.

Karen Smithson and Angela Robertson – Nurse Practitioners

Our Frailty Nurses carry out a comprehensive geriatric assessment looking at all aspects of clinical and social care, create a personalised care plan and encourage wellness and independence with the person who feels they are not coping with their independence as well as they used to. They can support patients through their difficult time, being a point of contact for the patient and their family. With their clinical background as Older Person Nurse Specialists and working for a long period in the hospital with Older Person Services they can provide the patient with a better understanding of health and try to avoid admissions to hospital.

Dawn Diston and Jemma Atkinson – Social Prescriber Link Workers

Dawn and Jemma are trained to support the practice and clinical staff with their knowledge of social prescribing.  They are available to advise and assist patients and carers with any issues of social need that is affecting their health.  This specialised role enables more time to be spent with a patient directing and supporting them through their stressful and difficult moments of life whilst coping with illnesses or social needs with an holistic approach