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Blog: Providing coordinated care for complex needs

Working collaboratively with other local teams ensures joined-up care for patients with long-term conditions.

Working collaboratively with other local teams ensures joined-up care for patients with long-term conditions

As a community matron, my role is to manage care for patients with the most complex needs. Recently, my role has expanded to include coordinating health and social care support for patients whose needs are predominantly health related.

I visit patients who have one or more long-term conditions – for example, diabetes, respiratory, heart, or neurological diseases. The new way of working means I can use my medical knowledge to anticipate changes in the patient’s condition or what might be required in the future, and put the practical steps in place so that the care is available when the patient needs it.

We already have a system in place for arranging care for palliative patients reaching the end of life, which is working well. This way of working builds on that system by expanding it to include patients who receive 100% Continuing Healthcare funding and whose social care assessments are complete. 

Following a multi-disciplinary meeting, I take over the case management from the social worker and become the key worker for patients with the most complex health needs. These are patients who I would visit anyway because of the complexity of their conditions. But rather than being on the periphery, I am now more involved with the support they need for their day-to day lives.

This is an advantage for patients because it reduces the number of different professionals coming through their doors, so they are not being repeatedly asked the same questions by different people.

Removing the need for a social worker to manage the care takes away one stage in the process and therefore reduces the time it takes to put care in place.

I believe this is a valuable extension of our role and a logical progression of what we are already doing to support our patients. We are experienced nurses, we have all the training we need for carrying out this role and it enables us to be directly involved with supporting the more complex patients who need us most.

As a patient’s needs become greater, they require more support and I can coordinate that for them. For example, I might have a patient with a progressive degenerative condition. As the disease progresses, so do the patient’s needs.

When initially diagnosed, the patient might be quite mobile and only experiencing early symptoms. However, as the condition develops, mobility may decrease, or the patient might develop problems swallowing or with breathing. I need to be aware of potential problems so an appropriate plan can be readily put in place. Liaising with GPs and other healthcare professionals helps the development of these plans. 

An example for extra care needed may be anticipation that a patient may require suction to clear oral secretions. I can discuss with the care providers to check if they can provide this service if and when the patient needs it. This gives the providers time to train carers to deliver that intervention so the patient can experience seamless and continuous care from familiar faces. 

If the patient’s social care needs should change, I can liaise directly with the brokers who arrange the care. The broker is part of the adult social care service in Northumberland, so let them know what the patient requires and they can arrange it. 

When people have very complex conditions, their needs are rarely purely social or purely health. As their condition progresses, their care package changes. My aim is to ensure seamless care for my patients so they get the support they need, when they need it. I feel that we are succeeding in this aim.