The Role of Community Matrons in Provision of Specialized Health Care Services to Identified Population Groups Affected by Multi-Co-Morbid Diseases

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The role of community matrons in provision of specialized health care services to identified population groups affected by multi-co-morbid diseases has gained relevance in the modern health care system. Community matrons have assumed the role of providing advanced clinical health care to critical and risky users through case finding and management. The aged and people suffering from chronic conditions which are the major cause of patient mortality are termed as the high risk users who form the basis for discussion in this paper.

            Randall in his work   entitled, “an exploration of embedding the community matron role in three settings: making the invisible visible?” argued a case for provision of nursing care by community matrons that involved the Evercare model (Randall, 2014). The Evercare model is portrayed as team of nursing practitioners in providing primary care which is intensive as well as preventative care to persons over 50 years of age with long-term conditions in the United States (US). The utilization of the Evercare model is critically evaluated and noted to help professionals in prioritizing and managing nursing care on continuous basis. The most essential aspect of priority is age in which the model prioritizes aged individuals with higher risk of hospitalization from long-term infections as well as high levels of multi-co-morbidity. Such comorbidity diseases include heart failure, diabetes, depression and anxiety conditions among others. Upon the prioritization of the high risk population, community matrons usually embark on proactive case management of the identified healthcare conditions through health care intervention in the daily lives of the target care group. Through need based assessments, community matrons are able to detect chronic and long-term conditions with the aim of promoting the health stability of for people living with chronic infections as well as co-morbidity infections. The community matrons also offer nursing care services to the high risk population at their homes thus reducing unnecessary hospitalization. The provision of care that has continuity is assured by the identification of persons likely to reap benefits from the  case management ,individual assessment of problems and needs for services, development of need -based care plans and mobilization of services to address the specific health needs, care plan implementation, regular review and monitoring of individual health progress.

            The role of inter-professional collaboration is imperative to satisfactory health care that ends in better patient outcomes (Trapani, 2014). As pointed earlier in the definition of community matrons, the application of a team-based approach forms the unshakable foundation to successful patient care and case management. Since the health care system is composed of various subsystems which are run by professionals from diverse disciplines such as pharmacy, nursing and medicine, the integration of professionals from such disciplines helps in focusing on a single patient from the diagnosis process through successful treatment as well as nursing care with enhanced efficiency as compared to a situation in which each discipline works on its own (Trapani, 2014). Furthermore, it is worth noting that the healthcare system has subsystems which are not autonomous but interdependent in providing quality healthcare services for the benefit of the patient. Any attempts to segregate a particular discipline would thus lead to the crackdown of the entire healthcare system.


            In summary, the role of community matrons in advancing healthcare to high risk population with proper case management is critical in ensuring health stability to persons with co-morbidity infections. Also, the inter-professional collaboration  aspect in healthcare is crucial in creating a harmonized health provision environment with successful patient diagnosis,treatment, nursing care and follow up activities to enhance patient outcomes.


Trapani,J. (2014). Critical care nurses as dual agents: enhancing inter-professional collaboration or          hindering patient advocacy? Nursing in Critical Care, 19(5), 219-221.     doi:10.1111/nicc.121

Randall, S. (2014) An exploration of embedding the community matron role in three settings:

            Making the invisible visible? Coventry: Coventry University.

October 13, 2023

Health Life Sociology



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