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Long Term Conditions Management

The Long Term Conditions team provides support to patients to help them manage their condition and works with other professionals to provide clinical treatment and care.

A long term condition (LTC) is a condition that cannot, be cured but is controlled by medication and (or) other treatments and therapies. There are around 15 million people (30% of the population) in England diagnosed with a long term condition.


187 Kent Science Park, Carver Drive, Sittingbourne ME9 8NP
Main: 0300 247 0400 

Gravesham Community Hospital, Bath Street Gravesend DA11 0DG
Main: 0300 247 0400 

e: VCL.DGSS-CCC@nhs.net

North Kent Adult Community Services Referral Form


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The LTC service works in conjunction with other members of the integrated primary care team to provide nursing care support to patients with a long term condition, a short illness and/or the frail elderly.

We manage the patient’s condition and additionally improve outcomes and experience, irrespective of the venue of care. We offer an equitable service for all patients living in registered with a GP in the Dartford Gravesham and Swanley CCG and Swale CCG localities who are diagnosed with a LTC.

We provide:

  • care in the patient’s home, preventing the need for patients to go to hospital to access care
  • providing advice and support on long term conditions for patients and their carers so that they can manage their care themselves
  • the provision of health promotion advice and guidance on disease management
  • support for patients with complex needs to better manage their health, which should go some way to help them live independent lives in the community location of their choice
  • encouragement of other family members to adopt a healthy lifestyle and monitor their own health
  • supporting the timely discharge of patients from acute settings back into the community location of their choice
  • delivering best practice by applying national protocols, procedures and pathways
  • general nursing duties
  • wound care
  • support and care for the frail elderly and to housebound patients
  • support and monitoring of a patient’s long term condition
  • end of life support to patients and families, including management of the condition and end of life care planning
  • nursing care to residential home patients registered with local GPs
  • identification and management of patients on their caseload at high risk of falls

The service will be provided in the patient’s home where they are registered with a GP in the Dartford Gravesham and Swanley and Swale CCG localities. As part of end-to-end case management, services will also be provided in community hospitals, acute hospitals and other locations as needed to support the individual patient. In-reach services are provided to support the discharge planning process.

Two wound care clinics are held in the Swale locality at Sittingbourne Hospital and in Sheppey.

Conditions supported by specifically trained clinicians

  • Respiratory – The community matrons provide a service across North Kent. They will provide condition management and support for people with lung disease and other chronic lung conditions in the community and in their own home. In addition to providing specialised respiratory care, Respiratory Nurse Specialists also provide Spirometry and Oxygen assessments.
  • Specialist Diabetes care  –  provided to service users in the Swale locality. Patient education and support for self-care is a major component of any care plan. This education is delivered with the consent of the patient together with members of the diabetes team
  • Cardiac care – The community matrons provide support and case management to people with cardiac conditions in their own homes. Patients also have access to specialist nursing providing cardiac rehabilitation, management of heart failure, left ventricular systolic dysfunction (LVSD) and cardiac diagnostics. The care encompasses assessing and taking responsibility for managing the medical needs of patients for Cardiac Rehabilitation and LVSD.
  • Tissue viability care – This service is provided by the community nursing teams in the DGS locality. In the Swale locality a specialist tissue viability nurse provides consultation, assessment and treatment for patients with complex and highly complex wounds and skin conditions, as well as assessment, provision, administration and review of patients requiring dynamic pressure relief equipment. The service provides an expert resource for advice to all services, as well as education and training to all services including GPs and practice nurses.
  • Community matrons provide services such as some nurse prescribing; physical examinations, diagnostic blood tests, ECGs, blood gases, microbiology cultures and holistic assessments. The respiratory and heart failure nurse is part of this team.

Exclusion criteria

  • Patients not registered with a GP in the Dartford Gravesham and Swanley CCG or Swale CCG localities
  • Patients under the age of 18 years
  • Patients with a primary diagnosis of mental ill health

Specifically:

General nursing
Patients with new diagnosis of severe disease who have no previous specialist assessment to eliminate other life threatening co-morbidity

Standard nursing care within nursing homes or hospitals

Cardiac service
Known long standing chronic AF on established treatment
Known structural heart disease
Previous cardiac surgery (should be referred directly to Cardiologist)
AF found at pre-assessment for any surgery (should be referred directly to a Cardiologist)
Associated syncopal episode (should be referred directly to a Cardiologist or A&E)
Lone palpitations with no clinical evidence of AF/flutter

Respiratory service
The oxygen delivery service is provided by another provider

Tissue viability
Housebound patients
Critical Lower Limb Ischemia
Spreading Cellulitis –Septicaemia
Acute Diabetic Foot Wound
Dermatological emergencies: necrotising fasciitis, bullous pemphigoid and erythroderma
Patients with chronic leg ulceration and lymphoedema
Burns greater than 20% deep dermal
Traumatic wounds requiring X-ray and plaster of Paris technician and initial trauma

Out of hours
Children under 18

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