Joining up care to meet individual need

A community service that wraps individual care around people with complex needs has been expanded by the West Suffolk NHS Foundation Trust (WSFT).

There are now six community matrons looking after patients in West Suffolk who have chronic, long-term conditions, helping them to achieve the best quality of life they can and preventing unnecessary admission to hospital. Expanding the service is part of the Trust’s drive to support alliance working, a partnership approach that brings together public, private and voluntary health and care providers to improve the lives of local people.

Sandra Webb is the community matron for Mildenhall and Brandon.

She said: “We support and empower people to manage their conditions and maintain their independence. As the care lead we co-ordinate colleagues from health, social care and voluntary agencies to meet individual need.”

Patients are referred to the service through a variety of routes and many are people who are often seen at the hospital or by their GP.

Sandra continued: “We do a home visit for a top to toe, comprehensive assessment of each patient’s situation – not just their health – and refer to other services as needed.”

The matrons also offer clinical leadership and support to the nurses, therapists and generic workers in the Trust’s six integrated neighbourhood teams.

Sandra’s colleagues are Shelley Lee with the Sudbury team, Sheila Burns with Haverhill, Caroline Ryan with Bury Town, Alison Salmon with Bury Rural and Kate Foxwell with Newmarket.

Sandra aded: “We work very closely with social care, often undertaking joint visits, as complex health needs will usually bring greater social care challenges. We liaise with specialist nurses to look after people at home and allow them to stay out of hospital where possible. Sharing information and pooling resources such as special equipment helps us to improve quality of life, prevent admission and save resources.”

The matrons are also increasingly working in partnership with the voluntary sector.

“People don’t necessarily know what is out there, but even a small involvement can make a big practical difference in their lives. There are ways to combat loneliness, such as befriending, outreach from the hospice or something as simple as a lunch club,” said Sandra.

Each matron has a caseload of patients she will support throughout their care, which may be long-term or shorter term as they approach the end of their lives.

Exploring the best ways to look after frail people over 75 is a focus for the WSFT, and the matrons’ work with hospital consultants and community assistant practitioners to ensure care is joined up between the hospital and the patient’s home.

The scope of identifying people in need of care is widening, explained Sandra.

“We are part of a WSFT initiative to identify patients who may not be visiting their GP or the hospital regularly, but do have significant health needs. Our aim is to see if we can help them have a better, more independent life.”

“Our focus is to fit the care around the individual, not to try and make them fit the system,” said Sandra. “Often I will walk in and the patient will say ‘I don’t know why you need to see me’. But at the end they understand what can be done to improve their quality of life and independence.”

Pictured above (left to right) are four of the six WSFT community matrons: Sheila Burns, Kate Foxwell, Alison Salmon and Sandra Webb.

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