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Home > Our services & hospitals > Complex Care Teams

Complex Care Teams

About Us

Complex Care Teams are integrated health and social care teams. They are focused on supporting people with long term conditions and/or complex needs stay well and independent in the community. The teams are made up of a range of health and social care professionals including – therapists, nursing staff, community matrons, social care professionals and representatives from the voluntary sector.

The complex care teams are organised into geographical clusters and some clusters have more than one team. The current clusters are:

  • Barnstaple.
  • Bideford, Holsworthy and Torrington.
  • South Molton and Ilfracombe.

What services are provided?

The services provided by each cluster vary but will include some or all of the services described below.

Community Rehabilitation Team

The community rehabilitation service is provided by a multidisciplinary team of physiotherapists, occupational therapists, speech and language therapists, community rehabilitation nurses and a rehabilitation doctor. The team aims to help you become as independent as possible. More information on this service can be found here.

Heart Failure Nursing Service

The heart failure nurse service is a team of specialist heart failure nurses who provide support and advice for patients with chronic heart failure, caused by left ventricular systolic dysfunction. More information on this service can be found here.

Cardiac Rehabilitation Service

The cardiac rehabilitation service is a specialist nurse led team who provide support for patients and carers; for patients who have suffered a heart attack, or have undergone either angioplasty (with stenting to the coronary arteries), or undergone heart surgery. More information on this service can be found here.

Lymphodema Service

The lymphoedema service offer support and treatment to patients suffering from lymphoedema in clinics at Barnstaple Health Centre. The team works with the community nursing teams to provide advisory visits to those who cannot attend a clinic. There are three members within the team, a Clinical nurse specialist, a specialist practitioner and dedicated administrative support (part-time). The team aims to provide a high quality service in line with current best practice for those patients suffering from lymphoedema or lipodema. More information on this service can be found here.

Community Palliative Care Service

Community Palliative Care service are provided in cooperation with local palliative care organisations e.g. North Devon Hospice. Exact arrangements vary between the clusters and if you require more information you should contact your local Complex Care Team.

Respiratory Outreach Service and Pulmonary Rehabilitation Service

The respiratory outreach service provides both respiratory nursing and physiotherapy expertise to patients, carers and other health professionals, contributing to the effective management of both acute and chronic phases of respiratory problems in the community.

The team members facilitate earlier discharge for patients admitted to acute hospital beds because of their lung condition, and liaise with other agencies to provide appropriate care and ongoing support to promote health and independence. The team encourage self management through ongoing education and exercise delivered in pulmonary rehabilitation programmes which are set in various locations across the community.

Community Nursing Team

The community nursing service aim to provide a service for people in the community with either acute needs or needs related to chronic illness but who do not need hospitalisation. Additionally, the community nursing teams work with other healthcare professionals to actively prevent hospital admission so that you can be cared for at home. Each team is based at either a community hospital or GP surgery and cover a geographical area. However, teams work flexibly to ensure that all areas can be covered. More information on this service can be found here.

Pathfinder Service

The Pathfinder team work with patient and carers to create a personalised care plan, so that a patient can return home or to another residential setting with the right support to stay safe and well. The team works with other services to provide multidisciplinary support from assessment through to treatment and care. The team aims to be as flexible as possible so that your needs are best met. More information on this service can be found here.