Community Matrons – Pioneering Solutions for Managing Multi-Morbidity in Patients
The “Community Matrons as Problem Solvers for People Living with Multi-co-morbid Disease” article by Randall et al. (2016) discusses the role of community matrons in addressing the needs of chronically ill patients. The model of care in this article aims to address patient needs while they are at their homes at the community level, hence reducing their high risk of hospitalization secondary to their conditions. The article further focuses on the role of the community matrons in addressing the social determinants of health. The article elucidates various aspects concerning the community matrons. Among the key aspects include their role in the community in providing comprehensive care to chronically ill patients, their scope within the community to address the social determinants of health, emphasizing patient-centered care, the expertise of the community matrons, the problem-solving strategies, and the challenges the community matrons face in their operation.
The model utilized in this article helps reduce the risk of hospitalization of patients with chronic illnesses. This is because the community matrons interact with the patients in their homes, which puts them in an ideal position to closely monitor the daily activities of the patients. By so doing, the community matrons can encourage the patient’s activities that promote health and advise on cessation of those that jeopardize the health of the patient. Therefore, this contributes significantly to the reduction of hospitalization incidences of the chronically ill (Randall et al., 2016).
Using a Real-World Example to Discuss the Utilization of the Article’s Case Management Model
This part of the assignment will consider a clinical case involving a 72-year-old man with a history of frequent admissions to the hospital. The 72-year-old man, Mr T, has diabetes, congestive heart failure, and chronic obstructive pulmonary disease. Mr. T’s case requires the community matron to apply a patient-centered care model to be able to prioritize the patient’s needs correctly and provide timely interventions to reduce the risk of complications and hospitalization. The use of community matrons in the management of Mr. T ensures care effectiveness and continuity through the use of various approaches.
To begin with, the comprehensive assessment is done by the community matron at the community level. This helps establish the causes of increased hospitalization, which might include non-adherence to medication, poor social support, and living standards such as proper housing and ventilation, safe water, and nutrition patterns. Secondly, the community matron helps solve Mr. T’s problems, as obtained from the assessment done by applying problem-solving skills. For instance, they can collaborate with Mr. T in the development of a medication adherence plan, as this helps the patient feel that his priorities are recognized and a part of his treatment. Also, the community matron can ensure access to community resources for support and collaborate with housing agencies to address housing needs (Putra & Sandhi, 2021). Addressing these factors prevents hospitalization and promotes the stability of Mr. T’s health.
Thirdly, to ensure continuity of care, the community matron serves as a point of contact between Mr. T and other healthcare providers and community resources to facilitate and coordinate his care. Regular communication helps the community matron monitor the progress of the client and recommend any adjustments required to address the ongoing current needs of the patient (Ljungholm et al., 2022). This interlinked interaction minimizes care gaps and reduces the reoccurrence of incidents requiring hospital admission.
The Role of Inter-Professional Collaboration and Its Effect on Patient Care
To effectively address the complex needs of Mr. T, inter-professional collaboration is paramount during the development of the plan of care for the management of the case. Resources need to be put together to address his situation, including community resources. To start with the comprehensive assessment of the patient, collaboration between the community matron and other health providers is required. Here, the community matron may focus on the social determinants of Mr. T’s case, while other factors requiring other professionals’ expertise may affect the case. Collaboration of these disciplines ensures comprehensive care is done and fosters the possibility of a correct diagnosis is formulated (Ljungholm et al., 2022).
Secondly, inter-professional collaboration ensures that holistic care of the patient is delivered. This is achieved when the community matron works with other health professionals to develop a comprehensive plan of care that addresses the medical and social needs of the patient. For example, the community matron may collaborate with social workers to link the patient to community resources while collaborating with respiratory specialists to address Mr. T’s respiratory problems. Thirdly, the collaboration ensures continuity of care by ensuring that all the team members involved in the care of Mr. T communicate about the case and evaluate the care outcomes. All the members share their professional input to ensure no fragmented or repeated care (Martin & Bryant, 2022). The fourth importance of the collaboration of community matrons with other professionals is that it makes access to resources easier, and hence, covering all medical costs becomes a lighter burden for Mr. T. Consequently, this improves overall living standards. The combination of efforts from different professional disciplines promotes the holistic care of the patient aimed to improve general health and improve activities that prevent and promote health.
References
Ljungholm, L., Edin-Liljegren, A., Ekstedt, M., & Klinga, C. (2022). What is needed for continuity of care and how can we achieve it? – Perceptions among multiprofessionals on the chronic care trajectory. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-08023-0
Martin, R. L., & Bryant, J. A. (2022). Collaboration. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK535400/
Putra, A. D. M., & Sandhi, A. (2021). Implementation of nursing case management to improve community access to care: A scoping review. Belitung Nursing Journal, 7(3). https://doi.org/10.33546/bnj.1449
Randall, S., Thunhurst, C., & Furze, G. (2016). Community matrons as problem-solvers for people living with multi-co-morbid disease. British Journal of Community Nursing, 21(12), 594–598. https://doi.org/10.12968/
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Question 
Instructions
1. Review the rubric to make sure you understand the criteria for earning your grade.
2. Select one of the following articles to read as the basis for this assignment:
a. Improve the Quality of Your Case Management Department through Staffing e
b. Effects of a Continuum of Care Intervention on Frail Older Persons’ Life Satisfaction: A Randomized Controlled Case
c. Community Matrons as Problem Solvers for People Living with Multi-co-morbid Diseases
3. Prepare to discuss the following prompts:
Community Matrons – Pioneering Solutions for Managing Multi-Morbidity in Patients
a. Using a real-world clinical example, discuss how the utilization of the case management model in the article you selected enables the professional to prioritize and manage care that has continuity.
b. Using the same example, discuss the specific role and function of interprofessional collaboration and its impact on patient care and case management.
4. Find at least two current scholarly sources to support your explanations and insights. OCLS resources are preferred sources and can be accessed through IWU Resources. Wikipedia is not permitted, as it is not a peer-reviewed, scholarly source.
5. Whether written or spoken, interactions are expected to:
a. clearly and thoroughly address the prompt with meaningful information that shows critical thinking.
b. introduce your own ideas and questions to add greater depth to the discussion, rather than restating what your classmates have shared. (Include much more than “Great post,” or “I agree.”)
c. refer to relevant course concepts as you discuss your learning together.
d. develop insightful conversation by directly addressing your classmates’ ideas.
e. demonstrate professionalism.
6. Based on your educational setting, complete tasks with the instructions below.
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