Transcript The Children's NSF: Opportunity or challenge?

Community Matrons
A Framework
Sally Bassett
Nursing Advisor
Modernisation Agency
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
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.
Levels of need
What can we do?
Level 3
Highly complex patients
Level 2
High Risk Patients
Level 1
70-80% of a Chronic
Disease Population
HEALTH PROMOTION
DH
Chronic Disease
Management; the growing problem
and strategic response
1
Case management
• Proactively 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 dependent on clinical need of
person
• Will help increase patients’ quality of life through a
personalised care plan and reduce unnecessary emergency
hospital admissions and reduce the length of hospital stays
Do you know
the names of
your VHIU?
Do you know how
many community
matrons and case
managers you need?
Community Matrons: 3000 by 2007
• They are nurses who are case managers for patients with
complex conditions and high intensity needs
• Provide case management that is user/carer led, maximises
choice and improves the quality of life for patients
• Other professionals are/will be case managers for patients
with less complex needs
• The community matron role is to proactively assess physical,
social and psychological needs, co-ordinate, manage and
evaluate the package of care
• This is a clinical role and community matrons will provide
clinical care as appropriate
Community Matrons: 3000 by 2007
Continued…
• They will ensure high standards of care are provided
• They will be visible and accessible to users and carers and
the local community
• Community matrons need to have the authority to mobilise
services, refer and order investigations (this may mean
holding a budget)
• 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
Do you know where
your community
matrons will be
recruited from?
Potential Workforce Competency Framework
Additional to
registered
competencies
Work based
Learning
Approach
Varied levels
of practice
6. Managing cognitive impairment
Competency Domains
Workforce
framework
Potential Community Matron Core Competency
Competency Domains
Additional to
registered
competencies
Work based
Learning
Approach
Potential at
Advanced level
of practice
Community Matron
Core Competencies
3. Care Co-ordination
Community Matron Competency Framework
community
matron
CM.D2 - Co-ordinate and review
the delivery of care plans to
meet the needs of people with
long term conditions
CM.D3 - Develop risk
management plans to support
individuals independence and
daily living within their home
Example of a Competence
CM.D2- Co-ordinate and review the delivery of care
plans to meet the needs of people with long term
conditions
This competence is about proactive co-ordination of
teams of practitioners to meet identified needs of people
with long term conditions in relation to their health and
well being.
The team(s) may be interdisciplinary or intra-disciplinary
and maybe drawn from one or more organisation or
agencies.
Teams may be established or put together as required to
meet the specific needs of people with long term
conditions.
Scope of
Competence
•The range of co-ordination may take place across statutory, voluntary
and independent settings.
•Arrangements that might be made include any necessary physical
arrangement within the environment; organising appointments and
arranging for others to be present.
•Carers could include spouse or partner other family members and
friends.
•Difficulties with the care plan that need to be resolved may include
communication interventions, resources, goals and expected outcomes
and non-compliance.
•Monitoring of the care plan will include whether the persons needs are
being met, the management of risks, the overall plan of care, the initial
assessment and the need for proactive reassessment.
Performance Criteria
Competence title – CM.D2 Co-ordinate and review the delivery of
care plans to meet the needs of people with long term conditions
Performance Criteria
6.1 Co-ordinate the delivery of care plans to meet the needs of
people with long term conditions
To perform competently you need to:
Ensure that practitioners have a shared understanding of the
person’s needs, interventions to be used and agreed goals for the
care plan
Discuss with practitioners how their interactions and interrelation
affect the co-ordination of their efforts and ensure they understand
their roles and responsibilities.
Knowledge and Skills Required
To perform competently you will need to know and be able to
apply the following knowledge and skills;
how to interpret and apply legislation to the work being undertaken
the roles of other health and social care practitioners and how they relate between and
across agencies
the impact of social relationships and environment on the health and well being of
people with a long term condition
the ways in which carers should be involved in communication in order to deliver the
most effective outcome for the person with a long term condition
the processes for information sharing and communicating within the team
methods of monitoring the person needs and the effectiveness of interventions in
meeting those needs