Service Detail

Telephone number: 0300 200 0011
Referral Criteria: Registered with Coventry GP; Self referral or health professional
 

Coventry’s Community Matrons are advanced practitioners and independent nurse prescribers who case-manage patients with complex long term conditions. Working closely with GPs, consultants, community nurses, specialist nurses, therapists, social services and voluntary agencies they aim to reduce the incidence of avoidable hospital admissions through a variety of interventions and support.

Community Matrons work with individuals who are at high risk of hospital admission, to help them to manage their own conditions more effectively and improve their quality of life by monitoring and co-ordinating care that is needed to keep them out of crisis. The level of care that is provided will depend on a person’s individual needs.

Community Matrons provide a 7day/week service and spend 50%of their time seeing patients and 50% of their time providing clinical leadership to the community nursing teams. They support the frailty pathway at UHCW to promote early discharge of patients. They also work in the Integrated Neighbourhood Teams which provide multi-disciplinary intervention to patients who may require a number of different health and social care services  to support them in the community.

Referral criteria:

1. Urgent referrals are accepted from GPs to prevent hospital admission and from UHCW to facilitate hospital discharge.

2. Routine referrals are accepted from GPs, other health professionals and hospital staff if they meet the following criteria:

 They have been diagnosed with two or more long term conditions, which are unstable/complex and which have a high impact on their daily life or activities;

AND

They have had two or more avoidable hospital admissions or ED visits within the last 12 months, or significantly increased contact with their GP or unscheduled care services.