People living with long-term conditions can be supported to have a better life with the help of community matrons and joined-up care, a Suffolk study has shown.
Last year five community matrons from Suffolk Community Healthcare (SCH), run by Serco on behalf of the NHS, monitored the care of 50 patients in their own homes in east Suffolk. These were people who between them had been admitted to, or attended, hospital more than 800 times in the previous six months. With the involvement of the matrons, who are senior nurses with advanced skills in clinical assessment, working closely with GPs, SCH community health teams and other services, hospital admission and attendances were reduced to 200 over the six months of the study.
The study recorded the times these patients went to accident and emergency departments or GP surgeries; were admitted to acute or community hospitals; or called out of hours doctors or the ambulance service. A significant reduction in the demand on all of these services was seen where SCH community health teams became involved via the community matrons. While the main benefits are helping people live well for longer in their own home and reducing pressures on the health service; this also represents a significant financial saving for the health economy.
The study highlighted that where an elderly person had a number of long-term conditions, they were not always aware of the range of services available and how to access them. The matrons were able greatly to increase their network of services and options. This might involve bringing in nurses, therapists and specialist services from SCH; social care; and accessing voluntary sector services; rather than relying solely on GPs.
Groups of patients were also supported by the matrons to manage their own conditions using a management plan. These plans signposted groups on to other services, provided standby medication and equipment and, most importantly, provided education on what to do if their conditions worsened. This new style of care co-ordination has been welcomed by all who have experienced it, and given a greater degree of independence for patients who often have difficulty accessing services. One carer whose husband has been living with a degenerative illness for the past 10 years said, “We could not manage without the teams.”
SCH community matron Joyce Feltwell, who is based in Felixstowe, said, “Our work allows us to treat the whole person and address all the problems they are facing, not just their health issues. Loneliness and isolation can be part of the problem, especially in rural communities, and we can help people by accessing voluntary services to provide support and companionship. So many people are unaware of the broad range of excellent services open to them. We are committed to helping people have the best life they can for as long as they can, despite living with complex health problems.”
By 2018, it is predicted that the number of people with three or more long-term conditions is due to rise from 1.9 million to 2.9 million, with 15 million people living with a single long-term condition. The NHS Five Year Forward View launched in 2014 stresses the importance of greater integration and co-ordination of services for people with long-term illnesses.
Many people in Suffolk are living with multiple and complex long-term conditions and greater integration and co-ordination of a broad range of services is offering more patients the right care in the right place at the right time. This study highlights the benefits this brings.