Community Matrons have advanced clinical and diagnostic skills and are responsible for the case management of patients with complex long term conditions. As well as case management, Community Matrons are responsible for providing treatment to patients (except when treatment needs to be provided by a specialist provider).
Each patient will have a personalised health plan and a Community Matron will oversee the care co-ordination and joined up services across health and social care.
The Community Matron service incorporates:
- Triaging referrals
- Carrying out advanced clinical assessment
- The development of care plans
- The case management and care co-ordination of the patient’s care
- Facilitating self care: educating patients, families and carers on how to move towards self management
- Health promotion
- Medication management
- Facilitating safe, early discharge of patients admitted to acute hospitals
- Liaising with a range of specialist nurses and other primary, appropriate place of care
- Liaising with GP practices regarding assessments and care plans put in place
- Maintaining effective communication with GPs and practice teams throughout care delivery
Where service is based
Community Matrons are based in a variety of local community settings aligned to Community Nursing Teams.
Please ask for a referral from one of the following:
· GP / practice staff
· Specialist nurses / Allied Health Professional
· Social services / social worker
· Hospital / hospice
· Third Sector services
Self referrals are also accepted when patients are already known to the service