Case Management:
Generalist Community Matrons
Whittington Health NHS Trust
District Nursing Service
Kat Millward
Overview
• Why the Community Matron role was
created
• Definitions of case management and
community matron
• My personal perspective on case
management
• Patient case studies
History
• Chronic diseases are the biggest cause of
disease burden, disability and death
across the world.
• Internationally, it is a policy priority to
improve the experience of, and service
delivery to, people with long term
conditions and their carers through multidisciplinary models of chronic disease
management (Challis et al. 2010).
History 2
• Case management based on Evercare Model
from USA with Kaiser Pyramid risk stratification
tool (Lewis 2011; Woodend 2006)
History 3
• The British population is ageing and health problems are
changing
• We need new and creative approaches to health, care
and support systems to meet the needs resulting from
these changes.
• As more people live into older age we need services that
support people to remain as well as possible for as long
as possible within their own homes and communities.
• The ambition is to
– increase the healthy years of life
– reduce the social isolation that many older people experience
– improve the quality of their lives
(DH, 2013)
History 4
• the involvement of community matrons
aims to improve health outcomes and
reduce emergency bed days (DH 2006).
• DH suggested case loads of
approximately 50 patients based on this
model.
Definitions
Case management- a collaborative process which
• assesses,
• plans,
• implements,
• co-ordinates,
• monitors and
• evaluates
the options and services required to meet an individual’s
needs.
This may be related to health, social care, education, and
employment
(Challis et al. 2010)
Ooh Matron!
(definitions 2)
• ‘old’ Matron role
different to ‘new’ or
‘Modern’ Matron
• Community Matron –
different role
altogether.
• CM could be seen as
Older Adult Nurse
Specialist
Definitions 3
Community Matron
• A community matron is a nurse who provides advanced
clinical nursing care as well as case management to an
identified group of very high intensity users (DH 2005).
• Experienced nurses, with advanced practice skills, using
case management techniques with patients who have
chronic diseases and very high intensity use of health
care. The aim is to support the patients to manage their
conditions, remain in their own homes, and avoid
unplanned admissions to hospital (Challis et al. 2010)
Case management
Social Services
Hospital Specialist 3
Housing
GP
Third Sector
Patient
Hospital Specialist 1
Hospital Specialist 2
CNS 2
CNS 1
Equipment provider
Allied Health (OT, physio)
Personal perspective in Islington
Caseloads between 20-45 (ideal would be
30)
Balance of direct patient care (health
monitoring & chronic disease
management; acute episodes) and
coordination/liaison away from patient
Often working with hard to reach populations
& previous non-engagement with health
Personal perspective in Islington 2
• 3-4 face to face visits each day
• MDT working
– monthly teleconference,
– GP meetings,
– case conferences
• Clinical advice and support to DN and other staff
• In office
– referrals,
– liaison,
– care planning
Personal perspective in Islington 3
Positives
• Autonomous role
• challenging & varied
• Close historic ties with social services
• Advanced nursing skills
• Holistic care
• Building professional networks
Personal perspective in Islington 4
Needing work
• Communication in both directions
• Information technology
• Integrated working
• Engagement (patients, other
professionals)
• how to predict patient engagement
Case studies of effective working
Rob
Medical history: Diabetes, heart failure, bilateral
amputee, lymphoedema, catheterised,
abdominal mass
Before: hospital admissions every 4-6 weeks with
worsening heart failure, urinary infection or chest
infection
After: Only 1 unplanned admission in 6 months
Decreasing admissions through assessment, early
treatment &social care
Case studies of effective working
Brian
Medical History: TB, COPD, cognitive
impairment (amnesia-dominant dementia)
Before: 36 ED attendances in 3 months
After: 5 ED attendances in 3 months
Reducing admissions through
communication, forward planning, PSP,
flexible approach
Case studies of effective working
Tony
Medical History: COPD, mild learning disability,
cognitive impairment (undiagnosed dementia),
alcohol dependence
Before: 3-4 ED attendances each month
After: 4 ED attendances in past four months
Increasing engagement, decreasing unplanned
admissions through liaison, supporting to attend
appointments, regular monitoring and social
issue resolution
Case studies of effective working
Donna
Complex medical history, long admissions to
hospital, multiple specialists
Medical history: pulmonary hypertension,
interstitial lung disease, rheumatoid arthritis,
heart failure, obesity, sleep apnoea, oxygen
dependent
Before: Between September 2012 and April 2013
spent approximately 3 weeks at home
After: No unplanned admissions. Has had 3
overnight planned admissions for investigations
Questions?
References
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Challis, D., Hughes, J., Berzins, K., Reilly, S., Abell, J. & Stewart, K. (2010).
Self-care and case management in long-term conditions: the effective
management of critical interfaces. Report for the National Institute for
Health Research Service Delivery and Organisation programme.
London: HMSO
Department of Health. (2006). Caring for people with long term
conditions: an education framework for community matrons and case
managers. London: HMSO
Department of Health. (2013). Care in local communities - district nurse
vision and model. London: HMSO
Grange, M. (2011). ‘How community matrons perceive their effectiveness in
case management’. Nursing Older People. 23(5), 24-9
Lewis, G. (2011). ‘Guess who’. The Health Service Journal. 121(6279), 23-5
Woodend, K. (2006). ‘The role of community matrons in supporting patients
with long-term conditions’. Nursing Standard. 20(20), 51-54.