COMMUNITY MATRON REPORT JAN 2005 – DEC 2005

COVENTRY tPCT

Case Management in Coventry

An evaluation of the first year of case management by community matrons

Annual Report: 2005-2006

Executive summary

As part of the demand management strategy to achieve the PSA target of a 5% reduction in emergency bed days by March 2008 (a reduction locally of approx 12,000 emergency bed days), Coventry tPCT took the decision to establish case management utilising a community matron model.

14% of the total practice population is aged over 65 years. Data revealed that 28% of emergency bed days were used by 5% (2,545) of our elderly practice population (65 years and over).

During 2005 a total of 7 community matron roles were introduced

  • 4 became operational start of January 2005
  • 2 became operational mid May
  • 1 became operational in August

They were placed within district nursing teams across all 6 localities and linked to 9 general practices (2 matrons work across 2 practices)

Details of criteria for identification of practices and suitable patients for case management are described within the main body of the report.

The aim of the service is to proactively manage high risk patients (initially aged 65 years and over) and empower them to take more control over their conditions and reduce the incidence of exacerbations and crisis. The service objectives are to:

  • Reduce the number of avoidable emergency admissions
  • Reduce the length of stay in hospital when an admission is unavoidable
  • Improve the patients medicines management and concordance
  • Enhance the quality of care
  • Improve continuity of care through better integration of health and social care providers

During the first year of the service data has been collected re:

  • Profile of high risk patients
  • Source of referral of high risk patients – and reliability of referral
  • Medicines reviews and outcomes
  • Number of admissions averted
  • Number and appropriateness of admissions of case managed patients
  • Services utilised to support high risk patients within the community setting
  • Qualitative - patient and user survey re impact and quality
  • Qualitative – health and social services experience/ perceptions of the service

All detailed within the main body of the report.

It is extremely challenging to measure the impact of case management, particularly in relation to preventing avoidable hospital admissions given the complexity of interventions involved for the patients, carer and range of service providers.

The community matrons have recorded incidences where they believe they were key in preventing an otherwise probable admission. These instances relate to particular events, such as an exacerbation, in which the matron had a crucial role in preventing an admission.

It is acknowledged that this data is subjective in nature, but all instances are logged and so auditable. The matrons have been cautious in claiming an admission was avoided through their intervention and so we believe the numbers are conservative.

In addition, it is not possible to capture the number of admissions that were averted in patients whose previous admissions were not due to exacerbations. A number of case managed patients have a history of 10 or more admissions for abdominal/ chest pain etc and have had a significant reduction since being case managed.

Over the 12 month the matrons have logged 139 averted admissions, however this is considered to be a conservative estimate as it is difficult to capture admissions avoided for patients who do not suffer acute exacerbations of their LTC, but nevertheless have a history of repeated admissions often for symptoms such as chest or abdominal pain.

Examples of this are described within the report.

95% of all patients assessed by community matrons had their medicines reviewed. In 32% of patients this resulted in changes to the patient’s medicine regime and patient concordance was reinforced.

Data shows that case managed patients had a total of 94 admissions during January 2005 – December 2005.

The community matrons kept records of all admissions and marked them as either appropriate or avoidable. Again this data is subjective in nature, but is supported with the rational for the decision. Each instance is logged and auditable.

Of the 94 recorded admissions 71% (67) were considered appropriate.

19% (18) were considered potentially avoidable and the matrons felt unable to make a judgement in 10% of instances, again the report contains examples to illustrate this.

The impact on the services required to maintain high risk patients at home is shown through the number of referrals to services. Unsurprisingly particularly high referrals were made to:

  • Social services
  • District nursing
  • Occupational therapy
  • Physiotherapy
  • Medical aids

It is worth noting that very few of the high risk patients were already known to district nursing, only 22%, and even less to social services, 18%, which means that this is additional work for these services.

The patient and user surveys rated the service extremely highly, particularly in relation to quality of care, communication and continuity.

Health and social care colleagues also rated the service very highly and almost overwhelmingly felt that from their experience it prevented avoidable admissions and made a significant improvement to patient care for this particularly vulnerable group of patients.

The evidence demonstrates better clinical quality and high patient & carer satisfaction. Although it is particularly difficult to evidence effectiveness in relation to hospital admissions, the data collected during the first year of the community matron service strongly supports that they are successful in averting avoidable admissions

One of the major strengths of this initiative is the co-ordination and continuity of the care that the patients receive.

We have learnt a lot about this group of patients, many of whom are frail and isolated, and are consequently anxious and depressed. Often they are suspicious of interventions and have a fear of being moved from their home and put into care. They need education and support to better understand and manage their condition(s) within their capability, concord with medications and to recognise when to ask for help/ support (exacerbation of condition) and have confidence in the health professionals.

Recommendations are made at the end of the report re future development.

Introduction

Coventry has a practice population of approximately 330,000, 14% (49,176) of whom are aged over 65. It is served by 64 general practices of varying sizes, of which 12 are single handed.

The total number of emergency bed days used by the PCT in 2003/04 was, 243,906, of which 70,000 were used by 2,545 patients aged 65 and over.

In other words 28% of emergency bed days were used by 5% of our elderly practice population (65 years and over)

In 2004, as part of the demand management strategy, Coventry tPCT took the decision to establish case management utilising a community matron model and initially funded 4 posts. These posts were filled in October 2004.

In January 2005 the DoH published 2 key papers on the management of long term conditions[1][2], which clearly set out the strategic direction and laid down a national target for the establishment of 3000 community matrons by 2008.

In light of this and the PSA target to reduce hospital admissions by 5% by March 2008 (a reduction locally of 12,000 emergency bed days), the PCT funded a further 2 posts, which formed part of the 3 year strategy to fully implement this service. The additional 2 community matrons were appointed in April 2005.

In July a further post was appointed as opportunistic funding became available and to date the PCT has 7 (6.8 WTE) community matrons in post.

The community matron service became operational at the end of December 2004 as the initial 4 community matrons completed their induction. The additional 3 matrons joined the service operationally in mid May and at the beginning of August.

The aim of the service is to proactively manage high risk patients (initially aged 65 years and over) and empower them to take more control over their conditions and reduce the incidence of exacerbations and crisis. The service objectives are to;

  • Reduce the number of avoidable emergency admissions
  • Reduce the length of stay in hospital when an admission is unavoidable
  • Improve the patients medicines management and concordance
  • Enhance the quality of care
  • Improve continuity of care through better integration of health and social care providers

Learning from some of the national pilots influenced the decisions on placing the community matrons. A key aim was to ensure that they would make a significant impact on the 2, 545 elderly high risk patients who were having 2 or more admissions each year.

The following criteria were used to identify the most appropriate general practices with which to link the matrons;

  • Proactive practices, preferably with a track record of innovation
  • Existing good relationships
  • Commitment from the GP’s to provide regular mentorship and support the community matron and a willingness to work in partnership
  • Sufficient numbers of patients aged 65 and over with long term conditions (LTC) and complex needs who would benefit from case management
  • The suggested total practice population eventually covered by 1 community matron of approx 25,000
  • Committed and motivated community nursing teams to support new ways of working

Additionally it was agreed that a community matron (CM) would be placed in each of the 6 localities to promote an equitable approach across the city.

From this 7 general practices were initially identified, however because of the level of interest an additional 2 practices were added, which resulted in 2 community matrons working across 2 general practices.

The community matrons were based within the district nursing teams linked to the GP’s with whom they worked. Being based with the district nurses is fundamental to the long term implementation of case management as it is envisaged that district nursing will play a significant role in the future care and management of patients with long term conditions.

Community matrons

Effective case management requires complex and highly skilled interventions. All 7 of the community matrons are very experienced nurses with excellent skills in working across health, social care and other key organisations.

  • 5 of them had been district nursing sisters (although 3 were in different roleswhen they applied, 1 was a clinical lead, 1 worked in nurse education and the other worked secondary care having established the REACT team).
  • 1 was a former health visitor turned practice nurse
  • 1 was from intermediate care.

Becoming an effective community matron requires a shift from traditional nursing to one that focuses on working proactively in partnership with the patient. It also requiresthe development of new skills and knowledge particularly in advanced clinical health assessment, medicines management and evidenced based practice in a range of long term conditions. A recent competency framework has been produced to support the development of educational programmes for this role and the DoH guidance is that study should be at master’s level.

  • 1 community matron has recently completed a Masters in Advanced Clinical Practice
  • 1 community matron is ¾ way through a Masters in Advanced Clinical Practice
  • 5 community matrons have recently commenced on a Post-graduate certificate in long term conditions (specifically designed for this role)

In addition community matrons are expected to adjust patientsmedication in order to optimise their treatment and in response to exacerbations.

  • 4 community matrons have completed the prescribing course
  • 3 will undertake the course as part of their development programme

Since coming into post all the matrons have built on their initial 6 week induction through a range of study days in order to develop the expertise to become effective within their new roles.

This has meant that during the first year a percentage of the matron’s time has been spent on professional development activities.

Partnership working

The success of case management is reliant on effective joint working across a number of disciplines within the PCT and across a range of other organisations and agencies. The community matron, although delivering some direct care, relies on a range of services to ensure the patients care needs are met.

At the point of initial assessment, many patients may be in a state of relative good health, (absence of an exacerbation). The referrals to other services at this point highlighted a range of unmet need (in often relatively stable patients).


Chart to show the services referred to following initial assessment

The service most frequently referred to was occupational therapy for assessment and interventions. Currently occupational therapists are members of the primary health care team in two of the six health localities in Coventry, additional occupational therapy resources being accessed via intermediate care. However, given the increased focus on adopting a proactive and locally responsive approach, it is important to ensure that occupational therapists become an integral member of future primary health care teams. In addition, due to the high prevalence of mental health and psychosocial problems in the population described, it is important to ensure that those with skills, knowledge and experience working with people with learning disabilities and in mental health are part of the future occupational therapy workforce in primary care.

However this does not accurately reflect the input of services required to maintain high risk patients at home, particularly during an exacerbation. The matrons began collecting data on all subsequent referrals made from August 2004 on a monthly basis.

The graph below shows the number of referrals made to a range of services for the months of August – November.

Series 1 = AugustSeries 2 = September


Series 3 = OctoberSeries 4 = November

The service most frequently referred to during those 4 months was social services. The main reason for the referral was for a change (usually an increase) in the patient’s package of care to support them at home as a patient’s condition has deteriorated, often following an exacerbation or crisis, or to support an early discharge.

Specialist nurses were also frequently used by the matrons to assist in joint assessments or as a source of expert advice. The specialist nursing service most commonly used was the COPD service, which accounted for 61% of referrals to specialist nurses. This was particularly high at the beginning of the year when the service was being established and the matrons had limited competence in assessing and managing patients with COPD. Initially a lot of assessments were undertaken jointly, but as their confidence and competence has grown the referrals have reduced. It also reflects the significant number of case managed patients who have COPD and that the initiation of case management coincided with the Met office project that involved the community matrons. Other specialist nursing services used included heart failure, diabetes, Parkinson’s, MS, tissue viability and continence.

Therapy services also had high referral rates. 55% of referrals were to physiotherapy and 45% to occupational therapy (OT). Although it is important to note that following initial assessment more than twice as many referrals are made to OT as to physiotherapy, which may reflect the preventative function of the OT role.

Currently most referrals for therapy are through intermediate care. This ensured that assessments and subsequent care were put in place rapidly. It has also allowed for evaluation of the therapy contribution required to support these patients at home so that it can be built into subsequent service development.

3 of the matrons also have direct access to locality based OT’s.They reported that the locality based OT service enabled more comprehensive OT interventions incorporating falls prevention work, confidence building etc which was sustained over a longer period and so was considered more effective. In addition, the close links meant that the matrons were enabled to develop their own expertise and so complemented and reinforced the work of the community OT.

A significant point to note is the high incidence of referrals to the district nurses. This is particularly pertinent given that only 22% of all the case managed patients were known to district nurses. This indicates that implementing case management successfully could have a significant impact on district nurses workload. Currently the teams which have a community matron based with them have supported the matron wherever possible within the constraints of their own workload, however this has resulted in not only additional pressure on the district nursing teams but also the community matron undertaking direct care that they would otherwise have passed onto other members of the nursing team. This issue is discussed further in the section on recommendations.

As part of the evaluation of the service, colleagues working with community matrons across health and social care were surveyed. 34 questionnaires were returned – though one, which was faxed was incomplete and unable to be used.

Respondents were as follows:

  • 11 General Practitioners (GP)
  • 5 nurses from community nursing
  • 1 Consultant – Old age Psychiatry
  • 3 Social Workers
  • 2 Therapists
  • 1 Podiatrist
  • 2 Mental Health nurses
  • 1 discharge facilitator – secondary care
  • 1 sister- intermediate care services
  • 2 specialist nurses
  • 4 unknown

When asked about the appropriateness of referrals to their services, it was reassuring that 100% reported that they felt community matrons referred appropriately.

‘Most community matrons access us for advice, particularly relating to equipment. They are very efficient and access advice promptly. I think they are doing a great job, well done’.

Tissue Viability Service, Primary care

Very knowledgeable and keen to share their knowledge for the benefit of all patients. Very keen to promote skills within others. Understands the role of other professionals very well and uses resources appropriately.

An excellent service.

Occupational Therapist – Primary Care

I have noted that they are more efficient and only use our service if necessary, quickly identifying packages of care and making sure these are in place and the patient comes off our service in a timely manner.