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COMMUNITY MATRONS

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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COMMUNITY MATRONS

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  1. COMMUNITY MATRONS

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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.

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. Thank you for listening

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