Community Matrons – Halton

General introduction

We support patients to self‑manage their health and help prevent avoidable hospital admissions.

This is achieved through advanced clinical practice skills, case management, and close engagement with other teams and services.

Community matrons have advanced training that enables them to clinically examine, diagnose and prescribe when required, allowing for early treatment and effective management of symptoms.

How to access this service

Referral criteria

The patient must have two long term conditions and two or more of the following:

three or more admissions in the last six months relating to long term condition
three or more emergency department (A&E) attendances in last six months relating to long term condition
recent admission less than four weeks duration relating to long term condition

Exclusion criteria

The service is not suitable for patients whose needs relate solely to:

sole management of dementia, health anxiety or mental health conditions
drug and alcohol issues harmful to health
frequent contact of GP services, not relating to long term conditions
sole social issues
sole completion of advanced care planning (ACP) / do not attempt cardiopulmonary resuscitation (DNACPR) and conversations surrounding this.

Referral form for professionals

Halton Community Matron Service referral form.

What happens after referral

Once a referral is received, community matrons aim to see patients within six weeks.

They will work with the patient to create a care plan that promotes autonomy and supports independence.

Patients typically remain on the caseload for around 16 weeks, or until they are medically optimised. At that point, they will be discharged back to the care of their GP.