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The Nursing Perspective The Nursing Perspective on Chronic Disease on Chronic Disease ManagementManagement

Sally BassettSally BassettNursing Advisor,

Modernisation Agency

The Management of The Management of LongLong Term Conditions Term Conditions

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What is the National Policy context?

Why is this a Nursing issue?

What is the evidence?

Who is the Community Matron?

What are the key challenges to developing the Community Matron role?

ContentContent

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www.dh.gov.uk

NHS Improvement PlanNHS Improvement Plan

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6600%% ooff aadduullttss iinn EEnnggllaanndd rreeppoorrtt aa cc hhrroonniicc

hheeaalltthh pprroobblleemm**

*Department of Health, Compendium of Information, May 2004

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0.10

% of Population admitted as inpatients % of Population admitted as inpatients by cumulative days spent as by cumulative days spent as

inpatientsinpatients Source: Analysis of British Household Panel Survey

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0.00 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

Percentage of inpatients

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lati

ve p

erc

en

tag

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f in

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ien

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ays

50% of inpatients account for 10% of all inpatient days.

10% of inpatients account for 55% of all inpatient days.

5% of inpatients account for 42% of all inpatient days.

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Integrated Health& Social Care

Systems

Supporting peoplewith long-term

conditions

LTCCommunity

SupportSelf-

ManagementSupport

ClinicalInformation

Systems

DeliverySystemDesign

Informed & Empowered Patients

Prepared & Proactive Practice Team

Long Term Conditions Case Long Term Conditions Case Management ModelManagement Model

Source: Department of Health, Working Model, October 2004

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Key Features of Established Frameworks Key Features of Established Frameworks for Managing Chronic Conditionsfor Managing Chronic Conditions

Not mutually exclusive approaches.

A range of approaches will be required to suit the locality

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& nurses

Source: Surrey and Sussex SHA

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Why LTC is a Nursing Issue?Why LTC is a Nursing Issue?

Nurse-led care improves health outcomes Effectiveness at patient education and self

care Care management well established Largest workforce Evidence shows the potential of nurses

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A PSA target to be Delivered A PSA target to be Delivered by Nursingby Nursing

To improve health outcomes for people with long- term conditions by offering a personalised care plan for vulnerable people most at risk; and to reduce emergency be days by 5% by 2008 (from the expected 2003/04 baseline), though improved care in primary care and community settings for people with long-term conditions.

Source: National Standards, Local Action, DH 2004

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Nursing Contribution is Nursing Contribution is About Being …About Being …

Personal – Care tailored to the individual patient or user

Caring – Providing high quality fundamental care

Partners – With patients users carers and colleagues

Professional – Taking responsibility and accountability

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What is the Evidence for What is the Evidence for the community Matron the community Matron Role?Role?

Internationally regarded primary care services

National projects such as the Castlefields Evercare UK Kings Fund

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‘‘CommunityCommunity Matrons… Matrons…

…through the unique combination of comprehensive assessment, proactive clinical intervention, marshalling of resources, assessment of the quality of care and co-ordination of acute primary and social care, enable people with multiple conditions, affecting all areas of daily living, to remain in control of their own lives’.

CNO bulletin, August 2004

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Community Matron RoleCommunity Matron Role Clinical role- no staff to manage Advanced clinical skills, medicines

management combined with Innovative case management Case loads of 50-80 With the authority to act ( this may include a

budget)

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SoSo What are the Key What are the Key ChallengesChallenges??

Developing the workforce Competencies, Education and Training Supervision and Mentorship Data and Information for case finding, risk management Systems Change and Integration with voluntary sector,

social care, primary, secondary care.

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Everyone's ChallengeEveryone's Challenge

“ Leaders are visionaries with a poorly developed sense of fear and no concept of the odds against them. They make the impossible happen”

Dr Robert Jarvik

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It’sIt’s What What PatientsPatients SaySay TheyThey WantWant……