Workforce Change Project in Long Term Conditions

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Workforce Change Project in Long Term Conditions
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Facts and figures

• Six in ten adults have some form of long-term
  condition
• 17.5 million people in this country suffer from
  such a condition
• Nearly half of sufferers have more than one
  condition
• 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

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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
  problems

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Levels of Need
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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

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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
  provided
• 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

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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
  prescribe)
• 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

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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

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Work in progress

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

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Evaluation of the Role Model

• Capture good practice and share
• Research proposal