Community Matrons provide intensive, personalised care and support to patients with at least one complex and chronic long term condition. The main aim is to ensure that patients can stay safe and healthy in their own home or in their chosen environment.
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The Community Matrons aim to reduce the need for patients to access unscheduled care as well as reducing unplanned re-admissions to hospital. If the patient is admitted, the Community Matrons aim to enable early discharge by working collaboratively with their colleagues in the local trusts. Individuals receiving continuing care will also be included in this service provision.
We provide support for those with long term conditions and the frail/elderly.
- Develop an individual clinical management plan with the patient, carers and relatives, which will include ways to overcome potential exacerbations of their condition
- Educate the patient and carers about the illness
- Support patients to self-manage their conditions
- Case Management
- Coordinate patient care across other Health and Social Care Professionals