Jennifer Tanfield, North Tees and Hartlepool NHS Trust

North Tees and Hartlepool NHS Trust were commissioned in 2016 to provide a community Matron service with a proactive approach to manage service users with Long Term Conditions to support and improve their health outcomes and to reduce the number of acute admissions to hospital.

In 2018 the Community Matron Service went through major transformational changes combining a proactive and reactive model of care with Community Matrons taking a lead role in both Residential and Nursing homes within the Hartlepool and Stockton localities. The agenda for this change was in line with the NHS Frailty Plan to help support people to age well, reduce mortality rates, lower acute admissions and assist in smoother transitions of care. This reform also supported the shortage of General Practitioner’s and their increasing workload as well as helping to educate and support care workers. 

Commissioner's and Clinical Managers were politically astute during this period, increasing funding to employ further Community Matrons with a wide range of knowledge and skills to address the needs of the service user. This included Nurses from District Nursing, Rapid Response, Orthopedics, Palliative Care, Neuro-medicine/Neurosurgery, Hematology, Mental Health and Drug and Alcohol Specialties. Community Matron's qualifications include Nurse
Prescribing and clinical assessment skills, qualification’s to ensure each service user is holistically assessed, diagnosed, treated where appropriate and a personalized plan of care is implemented. Extensive collaborative working and effective strategic influencing with managers, consultants and the North East Ambulance Service lead to direct admission rights, access to the Medical/Surgical Registrar on call to support and discuss clinical decisions and an 18 minute ambulance response for emergency situations in care homes. 

The impact this has had for service users is improved access to assessments and treatment for infections, rapid escalation to hospital if sepsis is suspected, immediate access to orthopedics, medical or surgical wards rather than via Accident and Emergency or Urgent Care. General Practitioners remain in charge of the service user care and act in an advisory role supporting Community Matrons.

The single point of access (SPA) service was developed alongside these changes. Referrals from care homes are faxed/emailed then triaged to the most appropriate clinical services. 

An important strategic development for North Tees and Hartlepool NHS Foundation Trust was to help educate and implement the National Early Warning Score (NEWS) into Care Homes alongside the Whzan digital healthcare tool kit. This allows the observational data to be processed electronically and accessed by Community Matrons and the SPA advanced clinical triage team improving decision making and ensuring the service user gains timely access to the most appropriate place of care. This has proven to be very effective in early detection of sepsis and accessing the sepsis 6 treatment pathway which is improving health outcomes. 

The Community Matrons role has been proactive in the education of Health Care Professionals in both the Trust, Care Homes, service users and their families, in relation to informed discussions, consent and completion of Do Not Actively Resuscitate (DNAR) forms and Emergency Health Care Plans (EHCP). 

The aim of EHCP is to provide a summary of diagnosis, indications and instructions of any rescue medications or care interventions that have been requested by the Service User, Families or Health Care Professionals. The ceiling of care should be clearly written instructing an escalation plan in an emergency or non-escalation plan to allow the service user to remain supported, well managed and cared for in the care home. These have ultimately enabled service users and their families to have greater control over the care they receive and the ability to be actively involved in discussions and decisions for the most appropriate setting for the delivery of care. 

In the current covid 19 pandemic EHCP plans have been very successful in helping all Health Care Professionals to work collaboratively in respecting Service Users priorities of care. 

Community Matrons were at the forefront of rapid covid testing and their ability to assess, diagnose and prescribe within hours and if necessary escalate to Hospital inevitably saved lives. However, sadly, some people did not recover and Community Matrons had to have very difficult and at times challenging conversations with residents and their families but these discussions were instrumental in implementing palliative care. 

Reflecting on national developments, Enhanced Health in Care Home weekly multi-disciplinary meetings were introduced with the GP, associated Matron, Community Mental Health, social care, therapy services and SPA team. The focus being a holistic coordinated and collaborative approach to care. Patients discharged from hospital into rehabilitation beds or on the Red pathway (complex discharges) are referred to the meetings to be monitored for a period of 8 weeks. This is improving continuity of care through early detection of problems. This helps ensure that the right care is provided closer to home, that people can be discharged from hospital in a timely manner and reduce unnecessary non-elective admissions / readmissions to hospital. 

Finally, in the summer of 2020 the Community Matron Service supported the development of a Community Hub and Deep Vein Thrombosis pathway. This has been a challenge initiating a new service during a pandemic, but it has had an impact on easing the workload and flow in Accident and emergency and Urgent Care so they have greater capacity to care for covid 19 patients and the Hub has provided a safer environment for DVT patients to be treated.

The patient journey has improved because they are assessed, investigated and treated within a couple of hours, due to rapid d-dimer testing, blood investigations and Ultra Sound Doppler scans (USS). 

Community Matrons are a small part of a much wider team within the NHS structure, but they have undoubtedly had a very big impact on supporting care staff, relatives and Service Users through a very frightening and unprecedented time. The collective knowledge and skills of colleagues have supported and guided us all through this period and has been a major part of reducing patient flow in the acute NHS Trust.