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COMMUNITY MATRONS. What is a community matron ?. Role started in 2003 as Evercare pilot sites in 9 PCTs nationally Developed from a case management model in USA working with complex patients resident in nursing homes Evaluated by University of Manchester and Imperial College.

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what is a community matron
What is a community matron ?
  • Role started in 2003 as Evercare pilot sites in 9 PCTs nationally
  • Developed from a case management model in USA working with complex patients resident in nursing homes
  • Evaluated by University of Manchester and Imperial College
advanced practice
Advanced Practice

4 Components to the role

  • Expert practice
  • Teaching
  • Research
  • Service Development

Percentage of time spent on areas varies with level of responsibility eg CM 75% expert practice

what does a community matron do
What does a community matron do ?

Work with people with complex conditions or in complex circumstances to;

  • Clinician – managing long term conditions, prescribers
  • Communicate – across agencies, with individual
  • Care co-ordinate – expert assessment, set up, monitor and evaluate appropriate care packages.
  • Coach – for patient and carer – better management of conditions and using services to advantage
  • Champion – for individuals and in service gaps
national picture
National Picture

Community matron/case manager role underpinned by national competency framework

All PCTs will have targets on numbers of community matrons

Integrated and co-located with social care

Virtual ward model with independent medical support

Integrated and co-located with GPs

Employed by practice based commissioning groups

strengths of cm service
Strengths of CM Service
  • Experienced, highly skilled nurses who feel passionately about care of older people.
  • High levels of patient satisfaction
  • Patient advocates – care plan focuses on issues of importance to the person
  • Lower case load numbers so time to co-ordinate care and avoid crisis
  • Responsible to lead care across settings and with other professionals and to make sure information is shared.
problems
Problems
  • Integration with one part of system can lose others
  • GP perceptions of the service
  • Links with hospital and OOH
  • Variations in role – how does CM work best ?
  • Case finding
  • Lack of leadership and continuity across UK
bristol picture
Bristol Picture

30 CMs based in practices

Caseload – some from data – others from professional referral, home visit book

Using GP IT systems

Link with OOH through IT system notes

Manage Band 5 nurses – community nurses for older people

Piloted joint approach with social care and PBC

Ongoing development and improvement cycle

the perfect service
The Perfect Service

Accurately predict which patients need this approach

Highly competent nurses or case managers who can expertly manage patients with complex LTC, develop shared care plan, share information, follow patient through settings

Shared records

Service fits within a pathway including primary, secondary and voluntary services

Expert medical input crucial

the future
The Future

Role of community geriatricians/GPwSI

Telehealth

Kings Fund Predictive Tool continuously developing to include social care data

Pathways across organisations – more flexible interfaces

More research to guide practice

case study one
Case Study One

Mrs B 57, asylum seeker, diabetes, hypertension, renal failure, Hepatitis C, Vitamin D deficiency

6 emergency admissions in 3/12, missed 4 hospital appts, 3 treatment room and 3 GP appts in 4 months

All correspondence from hospital in English, no transport booked, DNA when in patient, could not understand choose and book

CM liaised with depts booked appts with interpreter, translation for letters and for medication instructions

Co-ordinated investigations, organised system of planned appts and organised wheelchair

case study two
Case Study Two

Mrs L, 56 year old living alone with carers 4 x day. End stage multiple sclerosis. Abused by carers previously, 4 emergency admissions in 6/12 for UTIs

CM developed care plan with patient wishes at centre (does not want to go to hospital)

Co-ordinates district nurses, DART, SALT, continence, primary and secondary care

Educate carers to check for early signs of aspiration infection and urine infections and contact for early treatment

Develop end of life care plan

case study 3
Case Study 3

Patient with previous cardiac surgery – recurrent emergency admissions for chest pain. Usually phoned surgery and asked to phone 999

CM reviewed medication – using medication in adhoc fashion

CM stabilised medication to suitable regime by monitoring symptoms and side effects

CM educated patient and wife on impact of illness – worked with patient to distinguish and manage different types of chest pain. Referred to breathlessness and fatigue course