Community MatronNHS

Job summary

We are seeking an experienced and highly motivated individual to provide expert clinical leadership and intensive case management for patients in the community with complex long-term conditions who are at high risk of hospital admission. Working as part of an integrated multidisciplinary team, you will lead the assessment, planning and delivery of person-centred care, supporting admission avoidance, facilitating timely hospital discharge, and promoting independence through proactive care management.

The role involves managing a complex caseload, working closely with GPs, acute hospital teams, community services and social care partners to coordinate care, reduce unnecessary healthcare utilisation, and improve patient outcomes. You will provide clinical leadership, supervision and education to colleagues, contribute to service development and transformation initiatives, and support the implementation of innovative approaches to community-based care.

This is an autonomous advanced clinical role requiring excellent assessment, decision-making and care coordination skills, with a strong focus on preventative care, self-management, discharge planning and integrated working across health and social care systems.

Main duties of the job

• Manage a caseload of patients with complex long-term conditions who are at high risk of hospital admission, providing advanced assessment, clinical decision-making and personalised care planning.
• Deliver intensive case management to support admission avoidance, facilitate timely hospital discharge and promote patient independence and self-management.
• Work collaboratively with GPs, hospital teams, community services, social care and voluntary organisations to coordinate seamless, integrated care.
• Lead and contribute to multidisciplinary team meetings, providing expert clinical leadership and acting as a role model for best practice.
• Identify and proactively support high-intensity service users, developing proactive care plans to improve outcomes and reduce unnecessary healthcare utilisation.
• Use advanced clinical skills, including prescribing where appropriate, to assess, treat and monitor patients with complex and unstable health needs.
• Provide supervision, support and education to clinical staff, students and learners, promoting professional development and high-quality patient care.
• Contribute to service improvement, audit, quality assurance, innovation and transformation initiatives across community services.
• Support the use of assistive technology, health coaching and patient education to maximise independence and improve quality of life.
• Participate in integrated care pathways to ensure patients receive the right care, in the right place, at the right time.

Job description

The Community Matron is responsible for delivering expert, patient-centred care to individuals with complex long-term conditions, frailty, and multiple health needs who are at risk of crisis, hospital admission, or deterioration in their health and wellbeing. Operating as an autonomous practitioner within an integrated multidisciplinary team, the post holder will provide advanced clinical assessment, diagnosis, treatment, care planning, and case management to support patients in achieving the best possible quality of life while maximising their independence.

A key element of the role is the proactive identification, assessment, and management of patients with highly complex and unstable health conditions. The post holder will undertake comprehensive holistic assessments that consider the physical, psychological, social, and environmental needs of patients and their carers. Using advanced clinical knowledge and decision-making skills, they will develop, implement, monitor and evaluate personalised care plans designed to reduce health inequalities, prevent avoidable deterioration, and improve health outcomes. Interventions will focus on supporting patients to remain safely within their own home wherever possible, reducing unnecessary hospital admissions and facilitating timely discharge when admission is required.

The post holder will work closely with general practices, the Home Visiting Service, community nursing teams, acute hospital services, social care providers, and voluntary sector organisations to ensure coordinated and integrated care delivery. They will support patients through all stages of their healthcare journey, acting as a key point of contact and ensuring continuity of care across organisational boundaries. This includes facilitating effective discharge planning, supporting Discharge to Assess (D2A) pathways, monitoring patients admitted to hospital or step-up beds, and ensuring appropriate follow-up and intervention following discharge.

The role requires the proactive identification and case finding of patients who are frequent users of healthcare services or who are at high risk of unplanned hospital admission. Working collaboratively with GPs and multidisciplinary teams, the post holder will utilise clinical knowledge, available data, and information technology systems to identify vulnerable individuals who would benefit from intensive case management. Through early intervention and preventative care planning, they will seek to manage health risks, reduce crisis presentations, improve self-management, and minimise reliance on acute health services.

About us

East of England Community Health and Care NHS Trust delivers expert healthcare in people's homes, community hospitals and local settings across the East of England.

East of England Community Health and Care NHS Trust is committed to creating a modern and inclusive work environment. We actively promote flexible working opportunities where possible to meet the needs and wishes of our workforce and maintain and improve their wellbeing. We also offer flexible working patterns and we would encourage you to discuss this with the recruiting manager before or during the application process if this would interest you.

Please note, the selection processes at East of England Community Health and Care NHS Trust are in place to ensure we recruit candidates with the right values and skills, please be advised that the use of AI in applications are monitored. We remain watchful of candidates who misuse these tools to generate an application that doesn't accurately reflect their skills.