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Community Matrons work within the Integrated Locality Teams (District Nursing and Social Care teams) to provide expert case management for patients with one or more long term conditions who are identified as at risk of deteriorating health which may result either in an acute admission or impact on their quality of life.

They work with other key members of the primary health care team, other health and social care professionals, and carers, to develop and implement personalised care plans

They also maintain contact with patients if they are admitted to hospital to ensure integrated care is maintained. Community Matrons therefore help to prevent unnecessary hospital admissions, reduce length of stay in necessary hospital admissions, improve patient outcomes, improve quality of life and enable patients to manage their own conditions.

Community Matrons work with patients who present with a wide range of conditions e.g. diabetes, Chronic Obstructive Pulmonary Disease (COPD), Coronary Heart Disease, Parkinson’s disease, Multiple Sclerosis and HIV.

The Community Matrons are integrated within the wider District nursing teams and are based in two localities housed at one central base. Community Matrons work closely and in partnership with other services within YHC including the Rapid Response Team, Urgent Care Services, Specialist nurses, End of Life Lead and the Reablement team to provide joined up holistic care to our patients and their families.

The two District Nursing teams

There are two locality teams covering GP practices in New Malden, Worcester Park and Kingston (based at Hawks Road Clinic) and Surbiton and Chessington (based at Hollyfield House, Surbiton).

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