The community matrons work with people with long term conditions, at high risk of inappropriate hospital admission. The service is integrated with the district nursing & rapid response teams, GPs, social care, mental health professionals, the voluntary sector and acute hospitals.
The proactive care service aims to ensure those individuals and their families or carers have the advice, support and information they need to either regain or maintain their independence at home.
The service is available for adults aged over 18 who are registered with a Guildford & Waverley GP and who have complex needs living in their own or residential homes.
You will be referred by your GP, health or social professional or following an admission to hospital.
The community matron will visit you at home or in a clinical setting.
The community matron will work with you to provide an individualised care plan to help you remain at home and to prevent any unnecessary hospital admissions.
The community matron will be able to co-ordinate your care with other services such as social care and the voluntary sector to support your health and wellbeing enabling you to remain well and at home.
Please share details of medication that you are on or any discharge letters and any other services involved in your care.
Contact to the service is available through our Community Co-ordination Centre on 01483 362 020 which operates 365 days a year 8am - 8am.
Appointments will be arranged according to your needs.
We very much value feedback from all of our patients, and may ask you to complete a satisfaction questionnaire after your appointment.