Job responsibilities
Job Summary
The post holder will work and have a lead role in our My Care My Way service across the local Neighbourhoods and the ICS to deliver health improvement outcomes for patients.
Each Neighbourhood will have a chosen specialty that will be the focus for the health improvement outcomes identified by the Neighbourhood and the needs of the population. This will entail working within an ethos multi-professional model of care, that is committed to ensuring a culture of respect, collaboration and celebration of the multiple skills and contributions that the workforce can create.
Job Purpose
The post holder will -
Improve Integration and development of locally empowered Neighbourhood Teams.
Work with their Neighbourhood footprint to ensure it pulls together care across the system to allow coordination and improved response.
Focus on the key 1% cohort with multiple complex needs with data evidence of impact.
Work with the neighbourhood to reduce the contacts across the Partnership per individual to improve both outcome for people and the utilisation of clinical resource.
Ensure continuity of care and improved access which allows triage and direction to the designated teams and reduces transfers and complex navigation for the individual.
Recognise the value of partnership and seek to transform through outcomes.
Work in partnership with patients, carers, and families to support their care needs and provide ongoing navigation.
- All clinicians are provided with a work iPhone and iPad for mobile working and to access the electronic patient held record system, EMIS.
KEY RESPONSIBILITIES
Communication
To work within an ethos multi-professional model of care that is committed to ensuring a culture of respect, collaboration and celebration of the multiple skills and contributions that workforce can create
Act as an advocate for all individuals and carers to ensure a culture where individual needs, wishes and preferences are at the forefront of care
To work within a personalised care approach that supports care and develops a partnership approach with neighbourhoods
Constructively challenge tradition and take risks accepting joint responsibility for any arising problems and tensions and using these to inform future practice
Facilitate the Neighbourhood wide My Care My Way MDTs and provides clinical representation for nursing.
Actively contribute to meetings and participates in discussions concerning all elements of the aging well service and policy requirements
Demonstrate effective communication, joint working and networking across neighbourhoods
Works in partnership with hospital teams including specialists, Social Care, MDTs, and GPs, Voluntary services, charities in facilitating safe discharge home from hospital or following an A&E attendance
Interpret complex information and formulate solutions to recommend on the best course of action at individual patient level and at Neighbourhood level
Utilise complex data from a wide range of sources, some of which may be conflicting, to inform clinical decision making
Effective and contemporaneous use of electronic notes system, including assessment tools
Patient Care / Safety / Quality
Competent at Masters / level 7 to undertake physical examination of the circulatory, respiratory and other systems including listening to heart and lungs and regularly undertaking the following: venepuncture, male and female catheterisation, rectal examination, injections and wound care
Use advanced clinical assessment skills, Chronic Disease Management and End of life care to support personalised, anticipatory, and advanced care planning and the prevention of unnecessary admission to hospital for individuals and groups
Interpret findings from diagnostic tests/examination and uses this to make clinical decisions about care and treatment ensuring effective management of risk in the community setting
Seek to embed a proactive approach to promote wellness, early recognition of disease exacerbation, and appropriate intervention to improve patient outcomes through safe clinical decision making and the delivery of expert care
Ensure that patients and their carers experience a high quality, safe, responsive service, ensuring that care is accessible, effective, and delivered at a time and place according to clinical need
As an advanced and autonomous practitioner accepts clinical responsibility for a diverse and often complex caseload of patients, prioritising care needs efficiently and effectively
Receive referrals from and make referrals across all stakeholders within neighbourhoods.
Responsible for making rapid autonomous decisions, escalating as appropriate to the GP / Adult Social Care / Safeguarding in a timely manner
Work within the Surrey wide multi-agency safeguarding policy to ensure vulnerable adults are protected
Monitor individual and MDT wide indicators of long-term condition management, including the anticipating of possible decline and having effective personalised care plans in place
Service Development
Actively participates in service development and project meetings related to the My Care My Way programme to positively effect change, influencing change to integrate My Care My Way into practice
Effective delivery of presentations and effective chairing of MDT meetings
Actively participates in MDTs and risk stratification / population health management as required
Support service development for improved outcomes
Work with the wider team to help develop and evaluate the My Care My Way service across neighbourhoods, working with community and secondary care to continuously improving standards of patient care and wider MDT working
Works with the Professional Lead to establish relevant education and training
Utilise data and technology to systematically identify people at high risk of unnecessary admission to hospital, this is in conjunction with practice and PCN care coordinators
Effectively utilise technology to support communication channels and new ways of working, adhering to confidentiality and information governance
Assist with the development of data packs, including lightfoot and graphnet.
Is proactive in caseload identification and own caseload management.
Work with other streams of work in Procare Community Services to ensure best use of resources, no duplication and development of staff and services.
Professional Development
Accountable for own professional actions in line with the NMC code and local policy and guidelines
Maintain up to date technical and professional knowledge and clinical skills relevant to the post
Responsible for completing all own mandatory training and for overseeing direct reports
Participate in own annual appraisal
Access regular 1-1 meetings with line manager
Provide expert clinical and supervisory leadership to junior team members, non-registrants, new employees, and students within the team
