Community Nursing – Community Matrons


According to the National Health Service (NHS), a high quality care is proactive, coordinated and ensures that patients are provided with the right level of support for their respective needs. Hence, better health outcomes should be aligned with proper infrastructure and delivery systems to better provide incentives to improve the care for patients with long term conditions. In reality, however, the management of care is still very reactive, episodic and geared around acute problems. The challenge therefore is to respond to the needs and expectations of people with long term medical conditions. In contemplating what should be done to effectively manage care in accordance with the needs of older people with long term conditions is through creating a new role called community matrons.


Who is a community matron?

According to the Department of Health (DoH), a community matron is defined as a nurse who provides advanced clinical nursing care in addition to case management to an identified group of very high intensity users through case finding. Moreover, the service description of community matrons is proactively manage people with multiple long term conditions, supporting self care, self management and enabling independence through the sophisticated application of holistic person-centred approaches to care (Burke, 2006). The rationale behind such is to focus on people with the most complex conditions and needs who are the most vulnerable. Community matrons are commonly associated with patients with long term conditions or chronic medical conditions that cannot be cured but can be controlled and managed by medication and other intervention and therapies. Those who are eligible for community matrons, aside from the above mentioned, are those people who have had several emergency hospital admissions or are at risk of having to move their own home into a nursing home because of their condition (Department of Health, 2006).


Development of community matrons

The emergence of the community matron role is highlighted in the NHS Improvement Plan 2004 wherein experienced skilled nurses and who can utilise case management techniques with patients of high intensity need for care are deemed needed. The goal is to improve health outcomes and reduce hospital admissions (Harrison, 2004). The case management functions of this new form of specialist clinician encompass actively seeking out patients who will benefit, combining high level assessment of physical, mental and social needs, reviewing medication and prescribing medicines via independent and supplementary prescribing arrangements among others. Other functions include providing clinical care and health promoting interventions; coordinating inputs from all other agencies, ensuring all needs are met; teaching and educating patients and their carers about warning signs of complications or crisis; and, providing information so patients and families can make choices about current and future care needs (Department of Health, 2007).


Community matron roles in clinical nursing support the requirements of and acts in accordance with the National Service Framework for Long Term Conditions, a ten-year programme to improve health and social care services in England for people with long term conditions. The first quality requirement is a person-centered service which provides a single point of contact and with direct access to a healthcare professional. Other requirements are community rehabilitation and report, providing personal care and support, palliative care, supporting family and carers and caring for people with neurological conditions in hospital or other health and social care settings (Burke, 2006).


Moreover, the provision for community matrons is enveloped in the Case Management Competences Framework hence the Case Management Competences Framework for the Care of People with Long Term Conditions, with domains of competences discussed above. In general, competences acquisition aimed at helping to prevent unnecessary admissions to hospital; reducing length of stay of necessary hospital admissions; improving outcomes for patients; integrating all elements of care; improving patients’ ability to function and their quality of life; helping patients and their families plan for the future; increasing choice for patients; enabling patients to remain in their homes and communities and improving end of life care (Burke, 2006). 


High complexity needs-based community matrons  

Community matrons occupy the third level of the long term conditions model, with self management of long term conditions and high risk single condition disease management being at the first and second levels, respectively. In the level where community matrons are a necessity is intended for people with highly complex conditions requiring case management. One would understand that aside from having multiple needs, the overall health of these people render them to need nursing care. Community matrons usually serve as the case managers hence are required to have advanced clinical nursing practice to care for patients with complex and multiple long term conditions (NHS Modernisation Agency and Skills for Health, 2005). In the UK, six in every ten adults have some form of long term condition, contributing to 17.5 million people who suffer from such a condition. Nearly 50% of these sufferers have more than one condition. It is forecasted by the Department of Health (DH) that the percentage of over 65s with a long term condition will be doubled by 2030. The World Health Organization (WHO) also predicted that long terms conditions will be the leading cause of disability by 2020.


Competences framework of community matrons

Diverse and overarching competencies and expertise are essential for community matrons. This is because community matrons are expected to work in an autonomous manner to maximise choice and quality of life. In addition to being able to manage mental wellbeing and cognitive impairment alongside clinical care of patients, community matrons are positioned to assess physical, social and psychological needs of the patients. In providing case management that is user/carer led, community matrons ensure high standards of care are provided through effective coordination, management and evaluation of package of care. Specifically, community matrons are also obliged to assess, diagnose, prescribe and carry out treatments at home and initiate and interpret diagnostic tests as well as part of their clinical role. To manage exacerbation of long term conditions as part of extended prescribing also falls under the functions of community matrons. Nevertheless, community matrons need to have the authority to mobilise services, refer and order investigations. While also, they need to be supported by systems and be part of wider teams as community matrons will be visible and accessible to users and carers as well as to other health and social care professionals and local communities. Apart from working in homes and community settings, community matrons must be equipped with the necessary skills for interagency and partnership working. In this way, community matrons may be able to arrive at informed decision-making and effective treatment planning.


Community matrons and case managers basically provide the same intense level of service hence conforming to similar competences. Because of the expected functions of community matrons identified above, there are at least nine competences that community matrons must possess prior to emerging themselves in the work. Advanced clinical nursing practice is the most important competence as they have to be competent medical history taking and critical reasoning toward minimising the impact of compounding comorbidities. Next is to lead complex care coordination to ensure that community matrons are competent in proactive coordination, organisation and delivery of care. Being proactive also means to enabling patients to make informed choices about own plan of care. In managing cognitive impairment and mental wellbeing, community matrons should be also competent in assessment and recognition of deterioration and to refer to an appropriate specialist whenever necessary. Competence of community matrons should be also evident in enabling and promoting independence, dignity and choice to maximise independence. To ensure continuous competence, taking full responsibility on self-learning is likewise a critical competence as well as effective leadership behaviours. Community matrons, in addition, should be also competent in identifying high risk people as well as managing care at the end of life. Finally, community matrons should also acquire competence in terms of leading and working across organisational and professional boundaries to enable personalised, of highest standard care (NHS Modernisation Agency and Skills for Health, 2005). 


Improving care through community matrons

There are various ways by which a community matron could improve care for older people with long term conditions. These include preventing unnecessary emergency admissions to hospital, reducing length of stay in hospital, improving health outcomes for patients, integrating all elements of care, improving the patient’s quality of life and enabling patients to remain in their homes. In improving health and social care, community matrons are provided with the rapid and direct access to advanced healthcare professional through coordination schemes. Advocacy is a key. Increased choice and independence could be also endowed to the patients especially that community matrons are educated on various aspects of implementation of personal and self-management plans. Crisis support could be also provided including treatments within the homes of the patients, reducing the possibility of acquiring other severe medical conditions perhaps within the hospitals in case of rare to frequent admissions. Nevertheless, the goal is to reduce unplanned hospital admissions whenever possible and facilitation of early discharge if admission is required. Another critical element is education. Through a community matron also, patients could experience improved medicines management and immediate access to health education and promotion thus continuity of care (Burke, 2006).  


In a broader context, community matrons determine the population at risk which means looking at the whole population. Principally, the target service recipients are older people aged 65 years and over with a single or multiple long term conditions based on agreed upon criteria for the purpose of identifying those who could benefit from being in the case management system, and patients actively sought. Three indicators of vulnerability would be unplanned hospital admissions in the past six months, comorbidities and poly-pharmacy. Those who are at high risk as identified by professionals could be also included.


Consequently, the case management role of community matrons will: 1) take responsibility for around 50 older people with high level needs; 2) work collaboratively with all professionals, carers and relatives to understand all aspects of patients physical, social and environmental condition; 3) work in partnership with the patient’s GP, sharing information and planning together; 4) work as members of the primary health care team to ensure a team approach to care; 5) develop a personal care plan with the patient, carers, relatives and health professionals, based on a full assessment of medical, nursing and social care needs including preventative measures and anticipates future requirements; 6) keep in touch and monitor the condition of the patient regularly. This may be done by home visits or by telephone contact; 7) initiate action if required such as ordering investigations; 8) update patient’s medical records, and inform other professionals about changes in condition; 9) work in partnership with other local agencies such as social services, to mobilise resources as they are needed; 10) show carers and relatives how to identify subtle changes in condition that may precipitate acute exacerbation of underlying condition, or of illness, and to call for help; 11) generate additional support as needed, for example, from intermediate or palliative care teams, or geriatricians; 12) maintain responsibility if patient is admitted to any in-patient facility and provide base line health data for the receiving team, to support integrated and consistent care and facilitate timely discharge; 13) prepare patient and their family for changes in condition, and support choice about end of life care and 14) evaluate outcomes in collaboration with GP and hospital colleagues.


Patients with long term conditions build up considerable expertise from their own experience as service users. They, their families and carers are aware of what constitutes a good service and know why services can fail to meet their needs. However such people are not a homogenous group and while they share characteristics as a result of their illness, there are also many differences among them as in any other section of the population. Some of these differences may be cultural, gender and ethnic specific while others result simply from individual preferences or views about life. Providing personalised care means being attuned to the differences between one individual and the next. To ensure redesigned services meet a variety of needs it is vital to engage with a cross-section of the community who will be using them and to obtain as broad a view as possible. This can be done by liaising with established representative groups as well as using techniques such as rapid appraisal to gather perspectives from those not part of a formal system. Enabling more people to contribute to the redesign programme will help to establish support for the changes within the constituency most affected, and will ensure the changes achieve greatest benefits.


Good case management requires ‘whole systems thinking’. This is because all of the elements making up a comprehensive care package need to be co-ordinated and integrated. Where one element is missing, or of insufficient quality or quantity, the whole plan of care can collapse. Involving all key stakeholders, particularly social services departments, at the outset will help to build the commitment needed to ensure success. GPs are a vital link and should play a central role in developing the community matron service, as should those in acute and social care. PCTs will know who the key players are in their areas, and strategic health authorities and workforce development directorates can bring a consistency across the health community. Improving the care of very high intensity service users involves considerable organisational change.

Introducing community matrons to case manage those with the greatest burden of disease means many people need to work differently and with new partners. This will only happen if all of those affected are involved in a true partnership and competing priorities harmonised around the needs of the patients.

Establishing a steering group made up of all stakeholders can help to get the project established, keep it on course and help to ensure it delivers the desired outcomes.


Community matrons will need both theoretical and practical input to be effective case managers. Their theoretical and practice-based learning should also be underpinned by good mentoring and supervision. While the actual content of learning programmes should reflect individual need, it is likely all will require medical assessment and history taking skills, aspects of chronic disease, mental health, and the ageing process.

Some universities have developed specific programmes, and some PCTs have put together their own programme with local consultants and GPs. Skills for Health and the Institute for Skills, Learning and Innovation (formerly the Modernisation Agency and the NHSU) are defining community matron competencies to inform training programmes. They are also to develop a self-assessment module to enable potential community matrons to understand their own training needs.


Nurses advancing their clinical skills to become community matrons will need practical supervision while they are acquiring new competencies. They also need workplace mentors to support their continuing development. GPs are often willing to take on this work, but others such as nurse practitioners, geriatricians and other expert professionals may also be available. The supervisor or mentor should have a clear understanding of the level of practice the student is expected to achieve for each competency and enough opportunity to observe the student at work. A good relationship between supervisor or mentor and mentee is important and they should be able to discuss freely progress made and identify further training needs. Many senior clinicians enjoy sharing their expertise and developing others, but it is vital that they are aware of the time commitment involved and a plan devised to enable them to meet the obligation to students.


Improving the care of very high intensity users will require more than introducing community matrons. It involves considerable organisational change to make sure that the wider systems support this model of care. Introducing community matrons to case manage those with greatest burden of disease means many people may need to work differently and with new partners. Community matrons must be able to coordinate care across sectors and will need to be authoritative and knowledgeable about the needs of their patients.


The top of the triangle represents individuals with very high intensity needs. It is this group of people who are most likely to require case management by a community matron. This is because in addition to having multiple needs, their overall health renders them likely to need nursing care. Three of the most common reasons for unscheduled hospital admission in this group of people are respiratory problems, dehydration and urinary tract infections. These are among many conditions that can be treated in the home by a highly skilled nurse, providing for example, intravenous antibiotics. It is vital that community matrons are able to draw on a broad range of competences to handle most of the presenting needs, especially those requiring urgent intervention, and those which respond to preventative action. The community matron competences can be located on the enclosed CD.




Burke, S 2006, Service Specification for Community Matrons, DoH, retrieved on 3 April 2009, from


DoH, 2006, How a community matron can help you with your long term condition.

NHS Modernisation Agency and Skills for Health, 2005, Case Management Competences Framework.


DoH, 2007, The NHS Improvement Plan (2004).


Killick, S 2008, Community Matrons, Institute of Health Sciences, University of Reading.


Harrison, A 2004, The NHS Improvement Plan 2004, Briefing paper, retrieved on 3 April 2009, from


Workforce Change Project in Long Term Conditions, 2009, NHS Modernisation Agency, Department of Health.





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