Job summary
To work as a member of the Poole
Central Primary Care Network Enhanced Care Team (ECT) to assist with the
delivery of the clinical case management for frail and complex patients whom
are at risk of further deterioration in health or an avoidable hospital
admission or unnecessary length of hospital stay. To support the delivery of
the service, under the supervision of trained nurses, undertake a broad range
of health care activities and duties relating to the care of frail and complex
patients in the place where they live, usually in their own homes.
To assist with the identification of
frail and complex patients within the locality, supporting preventative care,
screening and patient education. To work strictly in accordance to specific
guidelines and agreed protocols. The
post will also include some administrative duties.
Main duties of the job
The focus of the role will be to
support the provision of clinical care for identified patients with frail
and/or complex needs usually in their own homes in accordance with the
patient’s care plan. They will work as part of a team supported by qualified nurses,
but the successful candidate must be able to work with minimum direct
supervision.
The successful candidate will assist
in the identification of those individuals with more complex health needs and
with discussion with colleagues, refer for an holistic, multi-dimensional,
interdisciplinary assessment. To participate in the MDT meetings, where
appropriate.
It will be essential for the successful
candidate to be able to establish and maintain effective communications with
patients, carers, and health professionals in a professional manner. To identify social isolation and
loneliness, being proactive in signposting the ageing well population to
relevant resources to empower patients to remain active and engage within their
communities.
Another focus will be to assist with
ongoing support of patients, their families, and carers to manage their frailty
and long-term health conditions. This will involve, following
appropriate competency-based training, to undertake delegated clinical tasks and procedures such as, phlebotomy,
ECG, bmi/bp readings, Urinalysis, diabetic foot checks.
About us
Poole Central Primary Care Network is a group of 6 GP Practices in
Poole, Dorset, covering a population of nearly 65,000. The practices work
collaboratively to create, joined-up, patient centred, community-based care and
support for some of our most vulnerable patients and their carer’s.
Our Enhanced Care service is well established multi-disciplinary team
of experienced nurses, paramedics, clinical pharmacists and administrative
roles working within the primary and community care setting in Poole Central Primary
Care Network.
This
versatile team deliver proactive care for the frail patients and those with
complex needs from across all 6 practices in Poole Central. They work in close
collaboration with the local community trust, secondary care and Social
Services teams with specific focus in the areas of frailty, and complex
care.
Job description
Job responsibilities
To support the provision of clinical
care for identified patients with frail and/or complex needs usually in their
own homes in accordance with the patient’s care plan. To be supported by the
ECT trained nurses but able to work with minimum direct supervision.
To establish and maintain effective
communications with patients, carers, and health professionals in a
professional manner.
To assist with ongoing support of
patients, their families, and carers to manage their frailty and long-term
health conditions.
To identify social isolation and
loneliness, being proactive in signposting the ageing well population to
relevant resources to empower patients to remain active and engage within their
communities.
To be able to identify and recognise a deterioration in an
individual’s health and act promptly to refer to relevant health professional
to minimise the risk of rapid deterioration or where appropriate, avoid hospital
admission. To have knowledge and understanding of the
NEWS scoring format to assist with effective communication in
acute/deteriorating presentations.
In line with the PCN/ Practices Team
policy, to update patient records ensuring entries are accurate, relevant, and
timely and communicate care provided appropriately.
Following appropriate competency-based training, to undertake delegated clinical tasks
and procedures such as, phlebotomy, ECG, bmi/bp readings, Urinalysis, diabetic
foot checks.
To support the facilitation of early discharge, where possible,
from hospital for case managed patients by co-ordination of care and services
to be delivered within primary care/community.
Job description
Job responsibilities
To support the provision of clinical
care for identified patients with frail and/or complex needs usually in their
own homes in accordance with the patient’s care plan. To be supported by the
ECT trained nurses but able to work with minimum direct supervision.
To establish and maintain effective
communications with patients, carers, and health professionals in a
professional manner.
To assist with ongoing support of
patients, their families, and carers to manage their frailty and long-term
health conditions.
To identify social isolation and
loneliness, being proactive in signposting the ageing well population to
relevant resources to empower patients to remain active and engage within their
communities.
To be able to identify and recognise a deterioration in an
individual’s health and act promptly to refer to relevant health professional
to minimise the risk of rapid deterioration or where appropriate, avoid hospital
admission. To have knowledge and understanding of the
NEWS scoring format to assist with effective communication in
acute/deteriorating presentations.
In line with the PCN/ Practices Team
policy, to update patient records ensuring entries are accurate, relevant, and
timely and communicate care provided appropriately.
Following appropriate competency-based training, to undertake delegated clinical tasks
and procedures such as, phlebotomy, ECG, bmi/bp readings, Urinalysis, diabetic
foot checks.
To support the facilitation of early discharge, where possible,
from hospital for case managed patients by co-ordination of care and services
to be delivered within primary care/community.
Person Specification
Skills & Attributes
Essential
- Excellent written and verbal communication skills
- Ability to use own initiative
- Demonstrable skills in written and spoken English, adequate to enable the post holder to carry out the role effectively
Experience
Essential
- Previous experience in an NHS / Primary Care / Local Authority role
- Experience of working under own direction
- Evidence of working with IT systems including Word
- Ability to handle sensitive information confidentially
Desirable
- Experience of supporting service improvement
- Ability to self motivate, organise and prioritise workload
Qualifications
Essential
- Qualification in Healthcare (minimum NVQ level 2)
Desirable
- Experience of Community\Primary Healthcare
Person Specification
Skills & Attributes
Essential
- Excellent written and verbal communication skills
- Ability to use own initiative
- Demonstrable skills in written and spoken English, adequate to enable the post holder to carry out the role effectively
Experience
Essential
- Previous experience in an NHS / Primary Care / Local Authority role
- Experience of working under own direction
- Evidence of working with IT systems including Word
- Ability to handle sensitive information confidentially
Desirable
- Experience of supporting service improvement
- Ability to self motivate, organise and prioritise workload
Qualifications
Essential
- Qualification in Healthcare (minimum NVQ level 2)
Desirable
- Experience of Community\Primary Healthcare
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Additional information
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
