Variability in selecting patients to manage in the community: a service evaluation of community matron's case-finding strategies

Abstract

Background. Community-based case management of high-frequency health service users, also termed ‘high-intensity users’ may reduce the demand on secondary care. In the UK, experienced senior nurses ‘community matrons’ have been appointed to provide more care in the community and to case manage high-intensity users and prevent unnecessary hospital admission. Computerized scoring systems have been developed to help with case finding. Objective. To evaluate how community matrons select their caseload, in particular the impact of a case finding tool, and access to computer-based systems. Methods. We used direct observation and the think aloud protocol during case selection and a series of workshops. Analysis was based on the Framework Approach (familiarization, coding, charting, mapping and interpretation) using verbatim transcripts analysed by N-Vivo software. Results. Community matrons within the same locality have different and sub-optimal caseloads. Although common elements exist in case selection, processes are modified by individuals depending on the influence of their interpersonal relationships, accessibility of computer systems and personal experience and expertise. The supporting IT system often produced data too late and while predicting admission did not identify cases amenable to community intervention. Conclusions. Inter-professional networks, personal experience and training influence the patients identified for case management. The combination of an improved case finding tool and a better defined role for community matrons could lead to more standardized and equitable case selection.