The Community Matrons in Islington are part of the care group delivering proactive care in Islington and known as Proactive Frailty and Complex Care Team (PROFACCT). The Community Matrons are also a core part of the Integrated Care Coordination Networks MDT (INC).

The aim of the Community Matrons Team is to prevent avoidable hospital admissions through the case management of patients with complex needs, minimising exacerbation of long-term conditions and providing advanced nursing care and therefore an alternative to admissions to the Emergency Department or hospital.

Referrals are accepted from health and social care professionals in primary and secondary care, as well as case finding through hospital in reach and regular involvement with multi-disciplinary teleconference and attendance at multi-professional meetings.

Eligibility Criteria

Inclusions

To access a community matron, patients must have consented to the referral and be:

• aged 16 years or above
• eligible for publicly funded healthcare
• resident in the London borough of Islington or registered with an Islington GP.

Additionally, they should have one or more of the following: 

• at least two co-morbidities and are presenting to their GP or secondary care provider with unstable multiple pathologies which impact on their daily life
• requiring long-term conditions management: optimising treatment, managing exacerbations and work in collaboration with specialist teams to improve patient outcomes
• be presenting to their GP or Emergency Department with an unstable long-term condition and Whittington Health does not have a nurse specialist to offer support with the presenting condition
• have a complex mix of physical, mental health and social care needs, impacting their quality of life or resulting in safeguarding concerns
• requirement for intensive case management to increase quality of life and minimise involvement of multiple services where clear leadership and care co-ordination is needed by a nurse with advanced skills
• been identified via the multi-disciplinary, Integrated Care Coordination Networks MDT (INC) as needing assessment and/or input (intensive or otherwise) by a Community Matron.

Exclusions

Patients will not be seen by a community matron if they have social care needs only.

Where the underlying cause of the presentation is solely caused by drug or alcohol misuse or an organic mental health condition.

Community matrons will discharge patients in the following circumstances:

• the patient has mental capacity and refuses to engage with the Community Matron input
• needs have stabilised and the patient can now self-manage
• the patient moves out of the area.

How to Refer