1. 27/10/2004 Developing the Role of The Community Matron-Improving CDM 1 The Nursing Perspective on Chronic Disease Management Sally Bassett Nursing Advisor, Modernisation Agency The Management of Long Term Conditions

2. Developing the Role of The Community Matron-Improving CDM2 27/10/2004 What is the National Policy context? Why is this a Nursing issue? What is the evidence? Who is the Community Matron? What are the key challenges to developing the Community Matron role? Content

3. Developing the Role of The Community Matron-Improving CDM3 27/10/2004 www.dh.gov.uk NHS Improvement Plan

4. Developing the Role of The Community Matron-Improving CDM4 27/10/2004 *Department of Health, Compendium of Information, May 2004

5. Developing the Role of The Community Matron-Improving CDM5 27/10/2004 0.10 % of Population admitted as inpatients by cumulative days spent as inpatients Source: Analysis of British Household Panel Survey 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 0.000.200.300.400.500.600.700.800.901.00 Percentage of inpatients Cumulative percentage of inpatient days 50% of inpatients account for 10% of all inpatient days. 10% of inpatients account for 55% of all inpatient days. 5% of inpatients account for 42% of all inpatient days.

6. Developing the Role of The Community Matron-Improving CDM6 27/10/2004 Integrated Health & Social Care Systems Supporting people with long-term conditions LTC Community Support Self- Management Support Clinical Information Systems Delivery System Design Informed & Empowered Patients Prepared & Proactive Practice Team Long Term Conditions Case Management Model Source: Department of Health, Working Model, October 2004

7. Developing the Role of The Community Matron-Improving CDM7 27/10/2004 Key Features of Established Frameworks for Managing Chronic Conditions Not mutually exclusive approaches. A range of approaches will be required to suit the locality

8. Developing the Role of The Community Matron-Improving CDM8 27/10/2004 & nurses Source: Surrey and Sussex SHA

9. Developing the Role of The Community Matron-Improving CDM9 27/10/2004 Why LTC is a Nursing Issue? Nurse-led care improves health outcomes Effectiveness at patient education and self care Care management well established Largest workforce Evidence shows the potential of nurses

10. Developing the Role of The Community Matron-Improving CDM10 27/10/2004 A PSA target to be Delivered by Nursing To improve health outcomes for people with long- term conditions by offering a personalised care plan for vulnerable people most at risk; and to reduce emergency be days by 5% by 2008 (from the expected 2003/04 baseline), though improved care in primary care and community settings for people with long-term conditions. Source: National Standards, Local Action, DH 2004

11. Developing the Role of The Community Matron-Improving CDM11 27/10/2004 Nursing Contribution is About Being … Personal – Care tailored to the individual patient or user Caring – Providing high quality fundamental care Partners – With patients users carers and colleagues Professional – Taking responsibility and accountability

12. Developing the Role of The Community Matron-Improving CDM12 27/10/2004 What is the Evidence for the community Matron Role? Internationally regarded primary care services National projects such as the Castlefields Evercare UK Kings Fund

13. Developing the Role of The Community Matron-Improving CDM13 27/10/2004 Community Matrons… Community Matrons… …through the unique combination of comprehensive assessment, proactive clinical intervention, marshalling of resources, assessment of the quality of care and co-ordination of acute primary and social care, enable people with multiple conditions, affecting all areas of daily living, to remain in control of their own lives. CNO bulletin, August 2004

14. Developing the Role of The Community Matron-Improving CDM14 27/10/2004 Community Matron Role Clinical role- no staff to manage Advanced clinical skills, medicines management combined with Innovative case management Case loads of 50-80 With the authority to act ( this may include a budget)

15. Developing the Role of The Community Matron-Improving CDM15 27/10/2004 So What are the Key Challenges ? Developing the workforce Competencies, Education and Training Supervision and Mentorship Data and Information for case finding, risk management Systems Change and Integration with voluntary sector, social care, primary, secondary care.

16. Developing the Role of The Community Matron-Improving CDM16 27/10/2004 Everyone's Challenge Leaders are visionaries with a poorly developed sense of fear and no concept of the odds against them. They make the impossible happen Dr Robert Jarvik

17. Developing the Role of The Community Matron-Improving CDM17 27/10/2004 Its What Patients Say They Want … Its What Patients Say They Want …