Case Management: Generalist Community Matrons

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Case ManagementGeneralist Community Matrons

• Whittington Health NHS Trust
• District Nursing Service
• Kat Millward

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Overview

• Why the Community Matron role was created
• Definitions of case management and community
  matron
• My personal perspective on case management
• Patient case studies

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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 multi-disciplinary models of
  chronic disease management (Challis et al. 2010).

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History 2

• Case management based on Evercare Model from USA
  with Kaiser Pyramid risk stratification tool
  (Lewis 2011 Woodend 2006)

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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)

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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.

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Definitions

• Case management- a collaborative process which
• assesses,
• plans,
• implements,
• co-ordinates,
• monitors and
• evaluates
• the options and services required to meet an
  individuals needs.
• This may be related to health, social care,
  education, and employment
• (Challis et al. 2010)

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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

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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)

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Case management
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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

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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

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Personal perspective in Islington 3

• Positives
• Autonomous role
• challenging varied
• Close historic ties with social services
• Advanced nursing skills
• Holistic care
• Building professional networks

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Personal perspective in Islington 4

• Needing work
• Communication in both directions
• Information technology
• Integrated working
• Engagement (patients, other professionals)
• how to predict patient engagement

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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

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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

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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

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Case studies of effective workingDonna

• 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

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Questions?
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References

• 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.