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Workforce Change Project in Long Term Conditions


Nearly half of sufferers have more than one condition ... NSF for coronary heart disease (CHD) has increased spending on life-saving ... – PowerPoint PPT presentation

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Title: Workforce Change Project in Long Term Conditions

Workforce Change Project in Long Term Conditions
Facts and figures
  • Six in ten adults have some form of long-term
  • 17.5 million people in this country suffer from
    such a condition
  • Nearly half of sufferers have more than one
  • The percentage of over-65s with a long-term
    condition is forecast to double by 2030
  • WHO says long-term conditions will be the leading
    cause of disability by 2020

The NHS and Social Care LTC Model
  • A blue-print for high-quality care which is
  • Proactive
  • Co-ordinated
  • And
  • Ensures patients get the right level of support
    for their needs.

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Progress so Far
  • National Service Frameworks set out standards
    of care for some conditions. NSF for coronary
    heart disease (CHD) has increased spending on
    life-saving stations by 30, potentially saving
    up to 7,000 lives a year
  • Deaths from CHD are down 23 and from cancer by
    10 since 1997
  • Expert Patient Programme spreading good self
    care and self management
  • Quality and Outcomes Framework for the first
    time gives practices incentives to improve the
    way they care for those with long-term conditions
  • But, management of care is typically still
    reactive, episodic and geared around acute

Levels of Need
Case Management
  • Focusing on those people with the most complex
    conditions and needs who are the most vulnerable
  • Care co-ordinated and planned by a case
    manager/community matron
  • Will help increase patients quality of life and
    reduce unnecessary emergency hospital admissions
    and reduce the length of hospital stays

Community Matrons 3000 by 2008
  • They are nurses who are case managers for
    patients with complex conditions and high
    intensity needs
  • Provide case management that is user/carer led,
    maximises choice and improves the quality of life
    for patients
  • Other professionals are/will be case managers for
    patients with less complex needs
  • The community matron role is to assess physical,
    social and psychological needs, co-ordinate,
    manage and evaluate the package of care
  • This is a clinical role and community matrons
    will provide clinical care as appropriate
  • They will ensure high standards of care are
  • They will be visible and accessible to users and
    carers and the local community
  • Community matrons need to have the authority to
    mobilise services, refer and order investigations
    (this may mean holding a budget)
  • They need to be supported by systems and be part
    of wider team that enables them to secure
    services when needed i.e. social care, in patient
    care, GPs, equipment, diagnostics and treatments
    and AHP services

In addition to their core nursing competencies
Community Matrons need to be competent in
  • Care co-ordination and case management (brokerage
    and provision)
  • Physical examination and history taking,
    diagnosis and treatment planning
  • Managing cognitive impairment
  • Using population and individual information to
    support decision making
  • Managing medicines (to include assess, review and
  • Interagency and partnership working
  • Management of long term conditions (particularly
    the interplay between multiple diseases)
  • Working in the home and community settings
  • Supporting self managed care
  • Managing care at the end of life
  • Advanced level professional practice, including
    self directed learning, managing risk, autonomous
    practice, higher level communication skills
  • Promoting health and preventing ill health

Community Matrons where we are now?
  • Priorities
  • Delivering the 3000 by 2007
  • Clarifying the role for the service and patients
  • Supporting the NHS (information, competencies,
    networks, local learning)
  • Gaining commitment from others (patient groups,
    GPs, the professions)
  • Promoting the role and title

Work in progress
  • Competencies articulation with Skills for Health
  • Production of KSFs outline
  • Supporting education programmes with NHSU

Evaluation of the Role Model
  • Capture good practice and share
  • Research proposal
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