Inter-organisational communication for patients being case managed by community matrons

Background Poor communication between community matrons (CMs), in-hours and out-of-hours (OoH) general practitioners (GPs) causes uncertainty and inefficiencies. Setting A practice-based commissioning group in West London and the associated CMs who case manage high users of hospital services. Question What helps good communication between CMs, GPs and OoH services to ensure that the right patients are case managed and hospital admissions are avoided? Methods Whole system participatory action research, with four stages: 1) identify communication problems as perceived by a wide range of stakeholders; 2) draw a diagram of the existing communication system, and with stakeholders redraw this to overcome its weaknesses; 3) pilot the changes proposed; 4) gain consensus among stakeholders about policy. Results Stakeholders agreed that standards should be adopted to improve communication for the care of patients who are case managed by CMs. Routine passage of information between GP, CMs and the OoH services would achieve this, and is feasible. Specifically: routine information (termed Special Patient Notes) should be sent to the OoH service about vulnerable patients, including those who are case managed by CMsclear information about CM attachment to general practices and how to refer to them should be easily accessibleGPs and CMs should meet quarterly for mutual learning and to discuss patientsthe OoH service electronically should cascade information to GPs, CMs and others named in the Special Patient Notescommissioners should routinely gather data to compare clusters of general practices for i) referrals to CMs, ii) posting Special Patient Notes, iii) unscheduled consultations and hospital admissions of all patients including those being case managed. Discussion This project revealed system-wide communication problems for the care of patients being case managed by CMs, and ways to overcome these. Commissioners could insist that these are adopted locally, and gather data to prompt compliance and evaluate the consequential cost savings.