ICN and Community Matrons

Overview

Community Matrons are part of the Integrated Care Network. The Community Matrons work with your GP to give you the care you need. They generally offer care to people living with ongoing ill health who may need extra support from a range of different out-of-hospital health services.

If you have a number of ongoing health concerns (long-term conditions) and/or have been in hospital several times in the past year due to your health conditions, then you would probably benefit from a visit from a member of the team who will then put together a plan for your care based on a full assessment of your medical, nursing and care needs. The plan includes ways to manage your health, so that you remain well for longer and anticipates any future needs you may have.

The Community Matrons will work with you, your carers and family to recognise changes to your condition that could lead to a deterioration in your health, and ensure that you know how to get appropriate help.

You will require a referral from your GP to receive support from this service.

The average waiting time for the ICN Proactive Care Pathway is 2.9 weeks.

To contact the service please call the Care Coordination Centre (number below) or email your area hub:

Integrated Care Network (ICN)

The Integrated Care Network (ICN) covers patients with a Bromley GP. We are based across 3 hubs. St Pauls Cray, Willows and Global House. The ICN team is made up of Community Matrons, Health Care Assistants and ICN MDT Liaisons.

Integrated care is all about healthcare being organised around what you need and then putting together a plan in which the different healthcare professionals you will work with, all coordinate within a Multi-Disciplinary Team (MDT) meeting to ensure you get the best outcome.

ICN is for patients aged 18+, registered with a Bromley GP.

The pathway mainly sees patients with frailty, but we do see many other patients with multiple comorbidities, social problems, mental health problems and carer stress or all of the above.

Patients are holistically assessed by a community matron using the comprehensive geriatric assessment tool.

The patient is then presented by the Community Matron at the Integrated care network MDT. The MDT consists of – a GP chair, the patient’s GP, Geriatrician, Community Mental Health representative, Social Care, Bromley Care Coordination/St Christopher’s and Care Navigators from Age UK.

The patient is discussed and all partners are invited to feedback and give input/recommendations for each patient.

External partners are invited to MDT if the patient is known to them, for example: Parkinsons and Multiple Sclerosis specialist nurses.

For professionals

To refer to the ICN Pathway, please complete the referral form below and email to the appropriate PCN hub:

Integrated Care Network Referral Form (MS Word)