Care Management

Care management is made up of two main services:

Community matrons
The matrons work with GPs to manage complex cases for people with long-term conditions. This is intended to prevent unnecessary admission to hospital, and to locate people with complex needs and prevent them getting into crisis.

Admission avoidance
This is a team of nurses and therapists who see urgent referrals. They work with patients and their families to try to either keep them safe at home, or manage the flow of patients into and out of community beds in Sandwell.

Services

Community Matrons help patients live with ongoing conditions. Patient who learn to cope and live with their condition require fewer visits to hospital and their GP. The service is individually tailored to each patient.

Matrons also work with nursing and care homes. They work with staff to provide training, support, quality and safeguarding. If urgent needs arise, the care home can call the patient’s dedicated community matron.

An alcohol community matron works with other organisations in Sandwell, such as Swanswell.

Referrals to admission avoidance usually come from GPs or the Ambulance Service. The nurses respond within three hours, with the service operating seven days a week between 8am and 8pm. They make sure that patients are safe, and have direct access to social services and packages of care.

The nurses build care packages to keep patients safe at home, or they can move them to a community bed if that’s the safest place. Once the patient is in a community bed, they will work to get them out of the bed and back to home, if possible, after a period of rehabilitation.

Contacts

To contact the Community Matrons or admission avoidance call: 0121 507 2664 and select option 5.