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

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

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.

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

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

Do you know the names of your VHIU?

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

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

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

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

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

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

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

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.

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.

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.

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