What We Have Done

The City Collaborative which includes Lister House, Hollybrook and Village Street surgeries have continued to hold weekly Community Support Team meetings and review the management of patients who have complex health and social care needs. The GP leads for each of these practices have supported the development of their Community Matrons and their roles. The Community Matrons have worked closely with identified care homes and built positive relationships with care home staff, providing education and continuity of care which has resulted in a reduction of GP visits. The Community Matrons have valued the support from the GP leads and advised that the development has  improved their job satisfaction. The next step is to explore how the Community Nursing teams attached to the practices can integrate and work more collaboratively with the Community Matrons and Practice teams.