Community matron service helps patients stay at home

A rapid response service led by community matrons is helping to reduce GP callouts and emergency hospital admissions across Middlesbrough, Redcar and Cleveland

A rapid response service led by community matrons is helping to reduce GP callouts and emergency hospital admissions across Middlesbrough, Redcar and Cleveland.

South Tees NHS Foundation Trust’s rapid response service was initially launched three years ago to enable nurses and therapists to assess patients in their own homes. The service has been further enhanced with the addition of 18 community matrons. The matrons have advanced clinical skills, including nurse prescribing, and particular expertise in managing patients with long-term conditions. The community matrons cover the Middlesbrough, Redcar and Cleveland area, and since their introduction, GP referrals to the service have risen from three to 16 per month.

Community matrons Angela Wells (left) and Claire Patchett

‘We have seen a big increase in referrals,’ says Val Gair, the trust’s head of nursing for integrated medical care.‘The GPs have a lot of confidence in the community matrons as they can offer advanced clinical skills, as well as being able to put in place management plans for patients. The service is also easing pressure on the system, as GPs don’t have to be called out or admit patients to hospital. Previously, around 75% of these patients would have ended up going into hospital.’

The changes to the rapid response service, which runs from 8am to 11pm seven days a week, were introduced as part of South Tees Clinical Commissioning Group’s (CCG) IMPROVE programme(integrated management and proactive care for the vulnerable and elderly). The CCG has seen a 3.9% reduction in emergency admissions over the past year. This compares to a 3.9% increase nationally.

Most difficult days

‘The service supports patients to manage through the most difficult days of their acute illness at home,’ says Janet Walker, chair of South Tees CCG. ‘Patient feedback has been extremely positive and patients and carers clearly value the care provided and avoiding admission to hospital.’

Patients are largely referred to the service by GPs or via NHS 111. All calls must be responded to within two hours. Each referral goes directly to the local community matron who will clinically assess the patient, make a diagnosis and devise a clinical management plan. The plan will include guidelines on medication, investigations required and parameters on blood pressure, heart rate and temperature. Patients are monitored by rapid response nurses over the next 72 hours. If there is a deterioration in the condition of a patient, their community matron is immediately informed. The matron will reassess the patient and create a revised clinical management plan.


Following the 72 hours, patients can either be discharged from the service or placed under the care of their local community matron. Patients that remain with the service have a range of long-term conditions. These include chronic obstructive pulmonary disease (COPD), bronchiectasis, heart failure, diabetes and chronic kidney disease.

‘We receive referrals for patients that GPs have identified using a predicted risk tool,’ says Claire Patchett, a community matron based in Middlesbrough. ‘The tool indicates when a patient is at risk of recurrent hospital admissions that could potentially be avoided. We also receive referrals from specialist nurses working in COPD outreach and from hospital teams. They refer patients to us that will benefit from a community matron to help them manage at home.’

The advanced clinical skills the community matrons have enable fast assessment and diagnosis for acutely unwell patients that have been referred to the rapid response service. ‘We are able to examine patients, perform a differential diagnosis and identify which investigations are required to confirm the diagnosis,’ says Angela Wells, a community matron based in Eston and Normanby. ‘We carry out full patient examinations looking at different systems within the body to determine if it is possible that one long-term condition is causing another. For example, a patient with COPD may develop right-sided heart failure. The clinical skills we have give us the expertise to identify that it is not an acute flare up, but a condition that is related to their long-term chronic illness. We are able to examine and diagnose patients as any medic can.’

The community matrons became part of the trust’s rapid response service in January. They combine this role with their own patient caseloads. The community matrons are the first point of contact when one of their patients is feeling unwell. This trusted relationship helps to provide reassurance and immediate support when it is needed.

Patient feedback

The trust recently carried out a patient survey on the rapid response service. Examples of patient feedback include:

  • ‘Aftercare from the nurses was brilliant; I was really looked after at home’
  • ‘Everyone could not do enough for me’
  • ‘The team was very helpful and got me through a bad time’
  • ‘Pleased beyond words’
  • ‘Five-star treatment’
Telephone advice

‘I have just started my shift and have already had a call from a grandson of a patient of mine,’ says Ms Patchett when I speak to her. ‘The patient is feeling a little breathless and has no rescue pack in the house as she has just used it on holiday. I am going to check her over, but I have given her some telephone advice to increase her nebulisers in the meantime until I can get to her. This saves patients having to make a trip to their GP practice when they are feeling unwell. It also saves the GP making a call out and the patient having to wait until the end of the GP’s working day to be seen at home. Our service prevents patients from panicking when they become unwell and calling 999. They have the reassurance that they know we will be coming out to see them.’

The community matrons access SystmOne to review patient information. If the patient has had recent investigations, such as blood tests or X-rays as part of a hospital stay, the matrons can also look at those results via the ICE system. Being able to access this recent clinical information enables the matrons to start patients on new medication or adjust the dosage of their current medication without delay.

SystmOne and ICE

SystmOne is an electronic health records system used by healthcare staff to record and share patient demographic and clinical information safely and securely across multiple care settings.

The web-based ICE (integrated clinical environment) system allows clinical requests to be made from wards, clinics and GP practices. The system also includes a feature that allows GPs and community matrons to view patient pathology and radiology results held by the hospital.

Multidisciplinary team

The matrons work as part of a wider rapid response multidisciplinary team for patients who require long-term care. The integrated community care team includes district nurses, physiotherapists and occupational therapists. This combined support for patients with long-term conditions helps to prevent avoidable hospital admissions. Between April 2014 and May 2015, 89% of the patients referred to rapid response therapy were treated at home rather than being admitted to hospital.

‘If a patient is unwell and is having difficulty getting secretions up, we can arrange chest physiotherapy for them within an hour,’ says Ms Wells. ‘If mobility is becoming more difficult, we can arrange for an occupational therapist to come and do a quick assessment to see if any home adaptations could be made.’

The service also has access to rapid social care to provide patients with extra support when it is needed. This can include regular visits to assist with medication, mealtimes or with washing and dressing.

‘Each time a patient has a flare-up of a long-term condition, the disease trajectory takes them a little further along the line,’ says Ms Wells. ‘This can lead to a short-term deterioration in their general health, though they always get back to where they optimally were. Admitting patients to hospital puts them at risk of further infections, which prolongs their stay. You are also taking away their independence. By putting everything in place to support patients at home, it is what they want and it is much better for them.’

Learning curve

As part of the community matron role in the rapid response service, the matrons are sometimes called on to carry out district nursing duties. Although this is very different from their usual role, this learning curve has helped to build good relationships with the district nursing teams.

Previously the community matrons and district nurses worked separately from one another. The inclusion of the community matrons in the service has helped to change this. Ms Wells feels the learning experience has further benefited the matrons by helping them to update their knowledge and brush up on skills where they have become a little rusty; for example, catheterisation.


More recently, the service has been extended to provide intravenous (IV) antibiotics in the community. This introduction followed research by the trust that found hospital stays could be reduced by 22 days per patient if IV treatment was made available in the community.

For the community matrons, promoting their expertise and making more GPs aware of the rapid response service is the next step. ‘It is good to know the GPs trust us,’ says Ms Patchett. ‘We have worked with GPs and built relationships with our practices over many years. The GPs know they can rely on us to clinically assess and put plans of action in place. We can have a huge impact and we are working to increase awareness so more professionals refer patients to us. The most rewarding part of our role is to see patients keeping really well. When your diagnosis and care plan makes a real difference to the health of a patient, it is just such a good feeling.’

Julie Penfold is a freelance health writer




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