Job Purpose
• To co-ordinate care provision through a case management approach with the aim to prevent unnecessary hospital admission and facilitate timely discharge. The caseload supports patients with multiple co-morbidities including frailty, COPD, Parkinson’s, diabetes, dementia, and CHD.
• To provide the highest standard of clinical care by using advanced skills and expert knowledge to holistically assess needs and instigate and provide clinical treatments based on evidence-based practice.
• To participate in the delivery of educational programmes to patients, carers and health and social care workers that promotes self-care principles.
• To develop and promote robust multidisciplinary team (MDT) working across the wider Health and Social care sectors, including care homes, to ensure integrated service and support networks for patients.
• To monitor the quality-of-care provision and to identify and promote areas for service development. To be the named Community Matron for a Primary Care Network (PCN), providing support and care coordination for the wider health team within the network.
• To provide clinical leadership and support to end of life pathways, including the Universal Care Planning (UCP) framework.
• To work in partnership with community health, social care and third sector organisations including care homes. Proactively case finding with GPs, district nursing colleagues and providing links across community nursing.
• Working closely with care home aligned GPs and care home staff to support and offer your expert advice.
• To work in partnership with acute Trusts through attending at high intensity user forums, linking with frailty and discharge teams and London Ambulance Service.
• To support and coordinate the Westminster Integrated Domiciliary Service.
• To work as a member of a PCN in line with the Westminster Integrated Care Partnership and the NWL Integrated Care Systems.
• Liaise closely with NWL Leads and CLCH Academy on any new initiatives and training to support the service.
We provide community health services to more than two million people across eleven London boroughs and Hertfordshire.
Every day, our professionals provide high-quality healthcare in people's homes and local clinics, helping them to:
• stay well
• manage their own health with the right support
• avoid unnecessary trips to, or long stays in, hospital.
We support our patients at every stage of their lives, providing health visiting for new-born babies through to community nursing, stroke rehabilitation and palliative care for people towards the end of their lives.
Our vision: deliver great care closer to home.
Our mission: working together to give children a better start and adults greater independence
• To use advanced skills and expert knowledge to carry out a thorough assessment and history taking, including a systematic physical examination, in order to develop a comprehensive care plan.
• To initiate, and provide, advanced clinical / therapeutic care treatments, in partnership with other providers, based on best possible evidence that will improve health outcomes.
• To use advanced clinical skills and expert knowledge to proactively identify subtle changes in a patient’s condition as early as possible and to manage these in a manner that optimises well-being.
• To take overall responsibility for coordinating the care, treatment, and complex health funded packages of care for case managed patients in a variety of settings. This includes planning, developing, implementing, monitoring, and reviewing specialised programmes of health interventions for case managed patients.
• To review and complete UCPs for patients.
• To work within the principles of the Single Assessment Process.
• To maintain responsibility if a patient is admitted to an in-patient facility. This includes actively accessing the acute sector to provide base line health data to appropriately the receiving team and initiating early discharge for case managed patients.
• To appropriately refer patients for a range of physical and functional tests and assessments, in order to inform decision making and care pathway development.
This advert closes on Tuesday 5 Nov 2024