This is a case management service for adults with long term conditions or who are at high risk of hospital admission. Short term interventions to support patient self-management and prevent unplanned hospital attendance/admission.
The Matrons,, who are based at West Park Hospital, pro-actively manage patients to reduce hospital admissions and lengths of stay. They provide a direct link between the acute trust and community services via an on-call community matron. They also support the acute trust with complex discharge planning.
The service provide patients with the knowledge and understanding of their long term health conditions to enable them to self-manage.
The Community Matrons within the team are independent non-medical prescribers with advanced physical assessment skills. The service is available citywide via:
South East Locality– Bilston Health Centre
South West Locality– West Park Hospital
North East Locality– Primrose Lane Health Centre