Case management 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.
Pro-actively manage patients to reduce hospital admissions and lengths of stay
Provide a direct link between the acute trust and community services via an on-call community matron. Support the acute trust with complex discharge planning.
Provide patients with the knowledge and understanding of their long term health conditions to enable them to self-manage
Provide 100% of all patients with multiple long term conditions an electronic personalised management plan which is accessible via hospital records.
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