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The role of the paediatric community matron

Debi Allcock
RSCN Dip BSc(Hons) MSc
Paediatric Community Matron in Respiratory Care
Cheshire East Community Health

In this article, Debi Allcock provides an overview of her work as a community matron in the area of emergency admissions avoidance for paediatric respiratory conditions, delivering education to children and families in their own homes

Research has shown that the projected cost of unnecessary emergency admissions for chronic respiratory conditions is in the region of £80m.1 The respiratory service in which I work has been running for approximately two years, receiving good patient feedback. When the service was set up we had very clear objectives for reducing emergency admissions in young people aged 0-16 years with common ambulatory respiratory problems, such as asthma, bronchiolitis and recurrent wheeze. We aimed to set clear, achievable referral goals as only one practitioner had been employed to meet this very challenging need.

The purpose of my role is to address the service gap between primary and secondary care, and to promote a service closer to home within paediatric ambulatory care. The package offers an holistic approach to asthma and respiratory management, working with families at their pace and level of need to better self-manage their child's condition. Fundamental to this is empowering the family through health education, support and advice. Our role is one of advocacy, co-ordinating a seamless service that avoids duplicity with the multidisciplinary care involved in the child's management.

The concept of shared responsibility between the healthcare professional and the young person with asthma and their family provides an opportunity for improved compliance. Unfortunately, this service is only available to patients living within the catchment area that is attached to the five GP practices within the footprint.

Meeting objective goals
The area in which I work is fairly deprived, with high rates of unemployment, large numbers of single parents and high levels of smoking. Predicted prevalence of asthma is approximately 5,260 people. It has been shown that, nationally, 5.1 million receive treatment for asthma and 1.4 million (approx 27%) are below the age of 16 years.1

Based on evidence from Asthma UK on health promotion, as well as the demographics of the locality, this was deemed an area that required specialist targeted health education and support. Providing such a service also meets recent guidelines and government agendas such as "Care closer to home" and "Modernising Community Services".2,3

The service uses a traffic-light system of analysis that quantifies the level of care provided to each patient. This approach allows us to effectively collect data and target those patients who are in and out of the hospital and GP system, accessing inappropriate emergency appointments. Those patients on "red" alert are at a level where their condition has deteriorated or is deteriorating, requiring intensive support to ensure an emergency admission is avoided. "Amber" is weekly support that requires a more direct look at healthy behaviour and reducing overuse of GP emergency appointments. "Green" is where education support has been maintained and the patient is in good enough health to be handed back to either the health visitor or school health system.

The concept of the role appears quite straightforward. The Children's National Service Framework (NSF) highlights in its asthma exemplar that children should be able to carry out normal activities and that assessment, diagnosis and early management of acute illness revolve around the linking of acute and primary care review.4,5

However, the challenges faced working in an area of such high deprivation and child protection incidence mean that barriers to achieving good asthma control are numerous. Literature has shown that this goes deeper than poor compliance to treatment. Social, environmental, family psychology and child-parent perception all impact on compliance/barriers to treatment and engagement with the service.6 Research has shown that children from deprived environments are at significantly higher risk of mortality and morbidity than those from more advantaged backgrounds.7

A recent study by Ungar et al demonstrated that visits from community respiratory specialists increased asthma awareness and reduced risk-taking behaviour.8 My anecdotal evidence on patient satisfaction supports this data. We find that these families operate on a day-to-day basis and cannot, or do not, think too far into the future. The complexities of stress and poverty in which they live often mean that they merely "crisis manage" their child's condition. Thus, the first hurdle I have to tackle is attempting to change this behaviour.

Role involvement
A large part of my work involves liaising and communicating with paediatricians, social services, health visitors and other multidisciplinary teams on the care I provide, the management plan and education suggested. Communication and trust are integral to these families engaging with the service so it is vital that all those involved are kept updated, and a progressive management plan put in place.

A major problem I encounter is parents forgetting to give the child their medication. The social environment is largely populated with single mothers, who often have large families with minimal support. Sometimes the barriers to compliance are due to such environmental circumstances. It is crucial that I have close working relationships with health visitors and school nurses because without their excellent communication skills and shared care for these children there would be disparity between care that stems partially from the poverty and cultural differences but also from the inconstancies that are imposed from practice to practice, through no fault of their own.

I am in the unique position of being a very autonomous practitioner. Once these children and families are case managed, they consent to share care. I therefore assess, diagnose, prescribe, treat and refer as appropriate. My role is one of leadership, where I develop a management plan in partnership with families that GPs are generally happy to follow. It is important that my role is integrated into the ethos of the general practice so that it runs smoothly for patients, care providers and healthcare professionals, and so that clear benefits of the post can be seen by all users.

Most families find the role non-threatening and supportive, and the majority embrace the support provided, contacting the service for support rather than their GP. The support given is dependent upon the family's particular requirements. The service is used by many illiterate families, and language barriers often arise due to the high population of Polish families in the area. To combat this, we have devised aids in picture format, with verbal support and written guidance supplied by
Asthma UK.

Implications for practice
This role is easy to replicate across the country, and cost savings have been clearly shown, making it an equitable service to run. However, some key aspects still need to be met. These include:

  • Targeting the right audience population, looking at demographics and service-level needs.
  • Establishing clear referral criteria.
  • Good data collection analysis.
  • Clear quality service provision.
  • Ensuring supportive infrastructure with room
  • to develop.
  • Good service agreement.
  • Good evaluation of data and quality audit.

Conclusion
This article has briefly outlined the considerations that need to be met in running a service with a targeted need. What I hope this article has shown is that it is working towards the Department of Health's "High Quality Care For All" agenda, and that we are providing a service motivated and moulded around the characteristics of the population and life indices.
Our patient data analysis questionnaires show that we have made a massive move towards meeting our target aims of reducing emergency admission. We have improved parental education and patient awareness of exacerbation and emergency management. GP use has decreased and high admission rates have reduced.

Even with lifestyle barriers, as community matrons we are providing a point of access for these hard to engage families, and we face the challenges head on, with drive, commitment and the determination to make a difference.

References
1. Asthma UK. Key facts and statistics. Available from: www.asthma.org.uk/news_media/media_resources/for_journalists_key.html
2. Doctor Foster Intelligence. Keeping people out of hospital, the challenge of reducing emergency admissions. London: Doctor Foster Intelligence; 2006.
3. Department of Health (DH). Delivering care closer to home: meeting the challenge. London: DH; 2006.
4. Department of Health (DH). Our health, our care, our say: a new direction for community services. London: DH; 2006.
5. Department of Health. National Service Framework for children and young people and maternity services. Children and young people who are ill. London: DH; 2004.
6. Fitzgerald JM. Psychosocial barriers to asthma education. Chest 1994; 106(4 Suppl):260S-2S.
7. Finkelstein JA, Lozano P, Farber HJ, Miroshnik I, Lieu TA. Underuse of controller medications among Medicaid-insured children with asthma. Arch Pediatr Adolesc Med 2002;156:562-7.
8. Ungar W, MacDonald T, Cousins M. Better breathing or better living? A qualitative analysis of the impact of asthma medication acquisition on standard of living and quality of life in low income families of children with asthma. J Pediatr Health Care 2005;19(6):
354-62.