1. Workforce Change Project in Long Term Conditions
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2. 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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3. 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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4. 16/05/2019

5. Progress so Far
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
Deaths from CHD are down 23% and from cancer by 10% since 1997
Expert Patient Programme – spreading good self care and self management
Quality and Outcomes Framework – for the first time gives practices incentives to improve the way they care for those with long-term conditions
But, management of care is typically still reactive, episodic and geared around acute problems
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6. Levels of Need
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7. 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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8. Community Matrons: 3000 by 2008
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 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
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
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9. In addition to their core nursing competencies Community Matrons need to be competent in:
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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10. 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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11. Work in progress Competencies articulation with Skills for Health
Production of KSF’s outline
Supporting education programmes with NHSU
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12. Evaluation of the Role & Model
Capture good practice and share
Research proposal
16/05/2019