Job responsibilities
For full job description and personal specification, please see supporting documents.
· Be a proactive member of the MDT, working with the Care Co-ordinator, Lead Clinicians and wider PCN MDT team to develop, and where appropriate update, personalised care and support plans for patients in care and nursing homes.
· Assess and triage patients presenting with acute illness or for review of chronic disease conditions.
· Diagnose, plan, implement and evaluate treatment/interventions and care for patients presenting with an undifferentiated diagnosis.
· Clinically examine and assess patient needs from a physiological and psychological perspective, and plan clinical care accordingly.
· Assess, diagnosis, plan, implement and evaluate interventions/treatments for patients with complex needs.
· Proactively identify, diagnose and manage treatment plans for patients at risk of developing a long-term condition (as appropriate).
· Diagnose and manage both acute and chronic conditions, integrating both drug- and non-drug-based treatment methods into a management plan.
· Prescribe and review medication for therapeutic effectiveness, appropriate to patient needs and in accordance with evidence-based practice and national and practice protocols and formularies.
· Work with patients and their carers in order to support compliance with and adherence to prescribed treatments.
· Provide information and advice on prescribed or over-the-counter medication on medication regimens, side-effects and interactions.
· Prioritise health problems and intervene appropriately to assist the patient in complex, urgent or emergency situations, including initiation of effective emergency care.
· Support patients to adopt health promotion strategies that promote healthy lifestyles and apply principles of self-care.
· Assess, identify and refer patients presenting with mental health needs in accordance with the NSF for Mental Health.
· Implement and participate in vaccination and immunisation programmes including but not limited to the management of the community-based flu season.
Expert Professional Practice:
· Recognise and work within own competence and professional code of conduct as regulated by the NMC/Health and Care Professions Council.
· Utilise and demonstrate sensitive communication styles, to ensure patients are fully informed and consent to treatment.
· Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating.
· Exercise a critical understanding of personal scope of practice and work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people to other health professionals within the PCN.
· Identify where there are opportunities for developing the scope and competence of the wider MDT to meet patient care needs.
· Through patient assessment and working in partnership with patients and their carers, make decisions about the best pathway of care, informed by the urgency and severity of patient need, patient acuity and dependency, and the most appropriate deployment of resources.
· Manage risk in unpredictable, uncertain situations to uphold patient safety, including by referring on to other primary care team members and to specialist services, as needed.
· Able to follow legal, ethical, professional and organisational policies/procedures and codes of conduct.
· Involve patients in decision making and supporting adherence as per NICE guidance.
· Liaise with the wider MDT and external agencies to deliver the patient’s personalised care and support plan.
Collaborative Working Relationships:
· Operate as a full member of the primary care team, including contributing to leadership, service evaluation/improvement and research activity.
· Manage and co-ordinate the care that individual patients receive, including through liaising with other members of the MDT and with patients' carers.
· Lead primary care activity, with a strong emphasis on prevention and early intervention, including through the delivery of public health advice.
· Contribute to the development of primary care teams, including through contributing to others' learning.
Leadership and Management:
· Demonstrate understanding of the Advanced Care Home Practitioner role in governance and be able to implement this appropriately within the workplace.
· Demonstrate understanding of, and contribute to, the workplace vision.
· Demonstrate ability to improve quality within limitations of service.
· Review the previous year’s progress and develops clear plans to achieve results within priorities set by others.
· Demonstrate ability to motivate self to achieve goals.
Demonstrate understanding of:
· The implications of national priorities for the team and/or service.
· The process for effective resource utilisation.
· Relevant standards of practice
· Ability to identify and resolve risk management issues according to policy/protocol.
· Follow professional and organisational policies/procedures relating to performance management.
· Represent the care home liaison nurse service on relevant committees and meetings, provide input in relation to specialist issues and clinical matters as required.
Education, Learning and Development:
· Understand and demonstrate the characteristics of a role model to members in the team and/or service.
· Demonstrate understanding of the mentorship process.
· Demonstrate ability to conduct teaching and assessment effectively according to a learning plan with supervision from a more experienced colleague.
· Demonstrate an understanding of current educational policies relevant to working areas of practice and keeps up to date with relevant clinical practice.
Research and Evaluation: Demonstrates ability to:
· critically evaluate and review literature.
· identify where there is a gap in the evidence base to support practice.
· generate evidence suitable for presentation at local level.
· apply the research evidence base into working practice.
· understand the principles of research governance.
· work as a member of the research/evaluation team, as required.
Confidentiality:
· While seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately
· In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers,
· Practice staff and other healthcare workers. They may also have access to information relating to the Practice as a business organisation. All such information from any source is to be regarded as strictly confidential
· Information relating to patients, carers, colleagues, other healthcare workers or the business of the Practice may only be divulged to authorised persons in accordance with the Practice policies and procedures relating to confidentiality and the protection of personal and sensitive data
Health And Safety:
The post-holder will assist in promoting and maintaining their own and others’ health, safety and security as defined in the Practice Health & Safety Policy, to include:
· Using personal security systems within the workplace according to Practice guidelines
· Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks
· Making effective use of training to update knowledge and skills
· Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards
· Reporting potential risks identified