2Facts and figuresSix in ten adults have some form of long-term condition17.5 million people in this country suffer from such a conditionNearly half of sufferers have more than one conditionThe percentage of over-65s with a long-term condition is forecast to double by 2030WHO says long-term conditions will be the leading cause of disability by 2020
3The NHS and Social Care LTC Model A blue-print for high-quality care which is:ProactiveCo-ordinatedANDEnsures patients get the right level of support for their needs.
4Levels of need What can we do? HEALTH PROMOTION Level 3 Highly complex patientsLevel 2High Risk PatientsLevel 170-80% of a Chronic Disease Population
5Case managementProactively focusing on those people with the most complex conditions and needs who are the most vulnerableCare co-ordinated and planned by a case manager/community matron dependent on clinical need of personWill help increase patients’ quality of life through a personalised care plan and reduce unnecessary emergency hospital admissions and reduce the length of hospital stays
7Do you know how many community matrons and case managers you need?
8Community Matrons: 3000 by 2007They are nurses who are case managers for patients with complex conditions and high intensity needsProvide case management that is user/carer led, maximises choice and improves the quality of life for patientsOther professionals are/will be case managers for patients with less complex needsThe community matron role is to proactively assess physical, social and psychological needs, co-ordinate, manage and evaluate the package of careThis is a clinical role and community matrons will provide clinical care as appropriate
9Community Matrons: 3000 by 2007 Continued… They will ensure high standards of care are providedThey will be visible and accessible to users and carers and the local communityCommunity 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
10Do you know where your community matrons will be recruited from?
11Potential Workforce Competency Framework Competency DomainsAdditional to registered competenciesWork basedLearningApproach6. Managing cognitive impairment8. Caring in the home and community4. Supporting self care management5. Interagency & partnership working7. Advanced clinical assessment9. Managing care at the end of life10. Promoting health & preventing ill health2. Managing Long Term Conditions11. Advanced professional Practice1. Managing Medicines3. Care Co-ordinationVaried levels of practiceWorkforceframework
12Potential Community Matron Core Competency Competency DomainsAdditional to registered competenciesWork basedLearningApproach1. Managing Medicines7. Advanced clinical assessment3. Care Co-ordinationPotential at Advanced level of practiceCommunity Matron Core Competencies
13Community Matron Competency Framework CM.D2 - Co-ordinate and review the delivery of care plans to meet the needs of people with long term conditionsCM.D3 - Develop risk management plans to support individuals independence and daily living within their home3. Care Co-ordinationcommunitymatron
14Example of a Competence CM.D2- Co-ordinate and review the delivery of care plans to meet the needs of people with long term conditionsThis 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.
15Scope of CompetenceThe 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.
16Performance CriteriaCompetence title – CM.D2 Co-ordinate and review the delivery of care plans to meet the needs of people with long term conditionsPerformance Criteria6.1 Co-ordinate the delivery of care plans to meet the needs of people with long term conditionsTo 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 planDiscuss with practitioners how their interactions and interrelation affect the co-ordination of their efforts and ensure they understand their roles and responsibilities.
17Knowledge 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 undertakenthe roles of other health and social care practitioners and how they relate between and across agenciesthe impact of social relationships and environment on the health and well being of people with a long term conditionthe ways in which carers should be involved in communication in order to deliver the most effective outcome for the person with a long term conditionthe processes for information sharing and communicating within the teammethods of monitoring the person needs and the effectiveness of interventions in meeting those needs