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Community matrons - a model for success

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By Rosemarie Best, community matron; Marion Fox, community matron and Heather Baker, director of primary care nursing on behalf of the community matrons steering group, Harrow Primary Care Trust.

By Rosemarie Best, community matron; Marion Fox, community matron and Heather Baker, director of primary care nursing on behalf of the community matrons steering group, Harrow Primary Care Trust.

Community matrons have recently been shown not to reduce hospital admissions in a study by Gravelle et al (1). We have been involved in a local pilot in Harrow, which has demonstrated positive results for patients and for our trust.

We would like to share some of the key messages from our pilot, which used a locally adapted scheme, based on the Castlefields model (2).

1. Our practice-based approach was successful in integrating the community matron into the primary health care team and ensuring that all General Practice team members were engaged in the process

2. We used a combined model method to identify very high Intensity users (VHIU?s). This included PARR (Patients At Risk of Readmission) version 1 data, (3)locally adapted criteria for VHIU?s from the Castlefields model (2) )and information from members of the individual General Practices.

3. Our initial focus was patients of 85 years and over, rather than 65 years, as this group was shown by our data to have the highest number of VHIUs in each practice.

4. As community matrons, we followed our patients across health and social care boundaries ensuring communication and continuity of care planning with formal and informal carers.

5. We recognised that stakeholder engagement at the start of the process was important to avoid the potential for antagonism with other healthcare professionals through the process of change.

6. By receiving education and training over the past year with multiprofessional, multi-agency mentorship as well as academic courses, we developed our case management and clinical skills.

7. It became clear early on in the pilot that the benefits of the community matron role would take at least one year to be demonstrated. We note that Black, in his editorial on this subject, comments on the longer time scale required to show benefits (4)

Our work highlighted the need for service redesign to ensure that VHIUs were provided with support from health and social care professionals in primary and secondary care, in a co-ordinated way. The role of the community matron with advanced clinical skills is central in facilitating this approach, providing clinical supervision for other nurses undertaking this care. We believe that a flexible locally adapted initiative focussing on case management of this client group can provide benefits for the patient and the NHS.


  1. Hugh Gravelle, Mark Dusheiko, Rod Sheaff, Penny Sargent, Ruth Boaden, Susan Pickard, Stuart Parker, and Martin Roland
    Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data
    BMJ, Nov 2006; doi:10.1136/bmj.39020.413310.55

  2. Castlefields Heath Centre. Chronic Disease Management. 2004

  1. Patients at Risk of Re-hospitalisation (PARR) case finding tool. Kings fund.

  1. David A Black. Case management for elderly people in the communityBMJ, Nov 2006; doi:10.1136/bmj.39027.550324.47
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