Community Matron

The Community Matron will: Proactively manage high risk patients with complex long-term conditions, deliver high quality care in partnership with the patient, carer, and other agencies in order to maintain independence, maximise quality of life, reduce the risk of avoidable hospital admission, and enable patients to die with dignity in their preferred place of care. Manage their own workload which will be a subgroup of the main integrated team caseload. Act as a support for advice, treatment, and management to the other caseload holders in the integrated team. Undertake comprehensive assessments of health and wellbeing, recognising the early symptoms of disease exacerbation, acute illness and injuries based upon the understanding of the chronic disease, the disease process, current evidence and practice standards. Manage care at the interface between Community, Acute and Primary Care services, preventing avoidable admissions and facilitating discharge. This is achieved through acting both