We help patients to self-manage their own health and to prevent avoidable hospital admissions.
We do this by using advanced clinical practice skills, case management skills and engagement with other teams and services.
Community Matrons have advanced training to clinically examine, diagnose, and prescribe for patients as required to allow for early treatment/management of symptoms.
The care we provide
Once referred into the service, the matrons aim to see patients within six weeks.
They will create a care plan with the patient in order to promote patient autonomy and maintain patient independence.
Community matrons will keep patients on their caseloads for approximately 16 weeks, or until they are medically optimised, at which point they will be discharged back to the care of the GP.
Referral criteria
The patient must have two long term conditions and two or more of the following:
- three or more admissions in the last six months relating to long term condition
- three or more A&E attendances in last six months relating to long term condition
- Recent admission less than four weeks duration relating to long term condition.
Exclusion criteria
- Sole management of dementia, health anxiety or mental health conditions
- Drug and alcohol issues harmful to health
- Frequent contact of GP services, not relating to long term conditions
- Sole social issues
- Sole completion of Advanced Care Planning (ACP)/do not attempt cardiopulmonary resuscitation (DNACPR) and conversations surrounding this.