Table 1.

Community based chronic disease services

Complex needs case management model	Respiratory service	Neurological service	Diabetes service
Site A	Site A	Site A	Site A
Community Matron model.	Led by respiratory nurse consultant with a team of nurse specialists, physiotherapists, and administration support.	Team of nurses and therapists.	Managed by a nurse consultant under a single budget with a number of diabetes nurse specialists.
Model adapted from United Health.	Medical consultant input though local and neighbouring acute hospitals.	Work with patients from diagnosis to end of life.	Provides community based clinics, education for GPs and practice nurses, structured self-management education.
Co-located with intermediate care teams.		Patients refer themselves in and out of the service as required.
Loosely attached to GP practices.
Site B	Site B	Site B	Site B
Integrated Community Team.	Covers all respiratory diseases and oxygen reviews.	3 specialist nurses.	1 diabetes nurse specialist and 1 Diabetes Practitioner Consultant.
One team per the three PCT localities.		22 bedded stroke and neurology rehabilitation unit.	Structured self-management programme is provided
Teams include community matron (case manager), district nurses, and therapists.	Led by a respiratory nurse consultant and team of nurse specialists and a physiotherapist.		Diabetes Nurse Specialist runs clinics in 2 GP centres.
Community matron & district nurses also attached to GP surgeries.	Provide pulmonary rehabilitation.