Monthly shout-out to the Community Matron team at Nottinghamshire Healthcare Trust

Congratulations to the Community Matron team at Nottinghamshire Healthcare Trust for winning this month’s shout-out.

The team works across Rushcliffe, Nottingham North and East and Nottingham West supporting older people living with moderate to very severe frailty. They help people to maintain their independence and remain in their chosen place of care. This improves the health outcomes of those living with frailty and allows for access to healthcare that would be difficult or impossible for this housebound population.  Provision of expert, proactive case management prevents unnecessary hospital admissions, reduces attendance at A&E and allows patients to remain living independently in their own homes, which is what patients tells us they want. 

The Community Matrons utilise a Comprehensive Geriatric Assessment approach to their care delivery which includes tackling issues such as falls, polypharmacy, advanced care planning, social care, mental health, maximising long term condition control and social isolation.  This proactive caseload management is achieved through successful liaison with social services and voluntary organisations and working closely with primary, mental health and secondary care. 

The matrons are the lynch pin to co-ordinate all the services that a frail, older person may require, ensuring that services work together to achieve the patient’s goals.  Working within a multi-disciplinary team, personalised care plans are discussed and evaluated in order to support a person’s health and social care needs. This illustrates the principles of prevention, equity and integration between health and social care.

Read about how they are making an impact on people’s lives:

Case study 1
“I will be 92 in June this year and I’m totally disabled with a rare form of myositis. My wife is nearly 85 and was registered as partially sighted some years ago, since then here eyesight has continued to deteriorate.

“I just came across the Matron Service when I was discharged from hospital late November 2022, I had been in hospital with pneumonia.  The matron came to my home to see how I was coping. She gave me a thorough physical examination and gave me advice with coping with the after-effects of my condition. She spent an hour with me and I was very relieved that the health services were looking after me. She returned at about two weekly intervals on a further three sessions to see how I was coping.

“I value her services as she is readily available for a home visit and very knowledgeable, and has time to deal with any problems or queries I may have. If it wasn’t for this valuable service, I would be requesting a visit from a doctor who might not be able to spend so much time with me. I regard this service as vital for people in my situation.”

Case study 2
“We have had the wonderful Community Matron, visit us over the last four months and she has made such a difference in our lives. My husband has a lot of illnesses with his diabetes, heart failure, COPD and kidney problems it was all getting too much for both him and me. The matron came to see us and explained that she was wanting to support us in looking after his health and to try and improve things where we could.

“She took over two hours on our first appointment and we discussed everything, she examined him head to toe and then we discussed a plan of action. She also helped us with sorting hospital appointments and that was such a help. She asked me how I was and directed me to carer support if I wanted to have it.

“The matron has been a wonderful, caring, kind and compassionate nurse. She is always on the end of the phone if we need her and nothing is too much trouble. She has sorted issues with medications, she ensured that services linked together so my husband got things he needed and she reassured him. She really listens to us both.

“We have been able to plan for the future and make sure that his wishes are written down and that was really good and when she left my husband said he felt calmer and listened to.
I can’t praise her enough really, she is a very special person with so much knowledge and expertise and I think she is a rare find in this NHS.”

Case study 3
“Our Community Matron supported us to navigate through a decline in health of my mother-in-law through Parkinson’s over the last year or so.  The matron anticipated her care needs and worked with many stakeholders and services to secure the best possible care in a timely, caring and professional way.

“Our Matron always put the wishes and needs of our loved one first and gave them and us as her carers a voice and a path through the challenging months before her eventual passing in December. She took time to get to know our loved one, building a relationship with her, the carers and our family. This allowed her to understand patient need and advocate for this and it built a very high level of trust for us all. We felt so supported throughout, we didn’t even know what we needed or what was available, and the Matron was able to gently work through what was ahead and ensure documentation, drugs, support services were aligned. This relieved a huge stress on us as a busy family, we were prepared for next steps and when the end came it was exactly as our loved one wanted – to be at home and in no pain. This brought an enormous sense of comfort at a very difficult time.”