Transcript Community Matrons: update

Workforce Change Project in
Long Term Conditions
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Facts and figures
• Six in ten adults have some form of long-term
condition
• 17.5 million people in this country suffer from such a
condition
• Nearly half of sufferers have more than one
condition
• The percentage of over-65s with a long-term
condition is forecast to double by 2030
• WHO says long-term conditions will be the leading
cause of disability by 2020
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The NHS and Social Care LTC
Model
A blue-print for high-quality care which is:
• Proactive
• Co-ordinated
And
• Ensures patients get the right level of
support for their needs.
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Progress so Far
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National Service Frameworks – set out standards of care for some
conditions. NSF for coronary heart disease (CHD) has increased
spending on life-saving stations by 30%, potentially saving up to 7,000
lives a year
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Deaths from CHD are down 23% and from cancer by 10% since 1997
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Expert Patient Programme – spreading good self care and self
management
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Quality and Outcomes Framework – for the first time gives practices
incentives to improve the way they care for those with long-term
conditions
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But, management of care is typically still reactive, episodic and geared
around acute problems
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Levels of Need
What can we do?
Level 3
Highly
Case
Management complex
patients
Specialist Disease
Management
Level 2
High risk
patients
Supporting care
And Self Care
DH
Chronic Disease
Management; the growing problem
and strategic response
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Level 1
70-80% of a
Chronic disease pop
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Case Management
• Focusing on those people with the most complex
conditions and needs who are the most vulnerable
• Care co-ordinated and planned by a case
manager/community matron
• Will help increase patients’ quality of life and reduce
unnecessary emergency hospital admissions and
reduce the length of hospital stays
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Community Matrons: 3000 by 2008
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They are nurses who are case managers for patients with complex conditions and high
intensity needs
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Provide case management that is user/carer led, maximises choice and improves the
quality of life for patients
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Other professionals are/will be case managers for patients with less complex needs
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The community matron role is to assess physical, social and psychological needs, coordinate, manage and evaluate the package of care
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This is a clinical role and community matrons will provide clinical care as appropriate
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They will ensure high standards of care are provided
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They will be visible and accessible to users and carers and the local community
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Community matrons need to have the authority to mobilise services, refer and order
investigations (this may mean holding a budget)
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They need to be supported by systems and be part of wider team that enables them to
secure services when needed i.e. social care, in patient care, GPs, equipment,
diagnostics and treatments and AHP services
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In addition to their core nursing
competencies Community Matrons need
to be competent in:
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Care co-ordination and case management (brokerage and provision)
Physical examination and history taking, diagnosis and treatment planning
Managing cognitive impairment
Using population and individual information to support decision making
Managing medicines (to include assess, review and prescribe)
Interagency and partnership working
Management of long term conditions (particularly the interplay between
multiple diseases)
Working in the home and community settings
Supporting self managed care
Managing care at the end of life
Advanced level professional practice, including self directed learning,
managing risk, autonomous practice, higher level communication skills
Promoting health and preventing ill health
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Community Matrons: where we are
now?
Priorities:
• Delivering the 3000 by 2007
• Clarifying the role for the service and patients
• Supporting the NHS (information, competencies,
networks, local learning)
• Gaining commitment from others (patient groups, GPs,
the professions)
• Promoting the role and title
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Work in progress
• Competencies articulation with Skills for
Health
• Production of KSF’s outline
• Supporting education programmes with
NHSU
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Evaluation of the Role & Model
• Capture good practice and share
• Research proposal
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