1. Nursing Advisor Modernisation Agency
Community Matrons
A Framework
Sally Bassett
Nursing Advisor Modernisation Agency

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

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.

4. Levels of need What can we do? HEALTH PROMOTION Level 3
Highly complex patients
Level 2
High Risk Patients
Level 1
70-80% of a Chronic Disease Population

5. 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

6. Do you know the names of your VHIU?

7. Do you know how many community matrons and case managers you need?

8. 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

9. 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

10. Do you know where your community matrons will be recruited from?

11. Potential Workforce Competency Framework
Competency Domains
Additional to registered competencies
Work based
Learning
Approach
6. Managing cognitive impairment
8. Caring in the home and community
4. Supporting self care management
5. Interagency & partnership working
7. Advanced clinical assessment
9. Managing care at the end of life
10. Promoting health & preventing ill health
2. Managing Long Term Conditions
11. Advanced professional Practice
1. Managing Medicines
3. Care Co-ordination
Varied levels of practice
Workforce
framework

12. Potential Community Matron Core Competency
Competency Domains
Additional to registered competencies
Work based
Learning
Approach
1. Managing Medicines
7. Advanced clinical assessment
3. Care Co-ordination
Potential at Advanced level of practice
Community Matron Core Competencies

13. Community Matron Competency Framework
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
3. Care Co-ordination
community
matron

14. 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.

15. 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.

16. 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.

17. 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