Home Visiting Nurse

Job responsibilities

The role is for a Registered nurse to join the Home Visiting Team consisting of Paramedic Practitioners, Paramedics, Nurses and Health Care Assistants.

Job Summary:-

This is an innovative, clinically led Home Visiting Service, Channel Health Alliance is an independent organisation which comprises of GP Practices across South Kent Coast Localities, working with and supported by the CCG.

The post holder will work within an integrated Primary Care Team to proactively support practices across South Kent Coast and provide unscheduled Home Visits.

The roles will support patients with multiple complex long term conditions (experiencing exacerbations) and those with shorter term health issues, with responsibility for ensuring all health and social care needs are met to improve health outcomes. This aims to prevent avoidable admissions to hospital and managing the length stay in short-term, step-up recovery beds.

Clinical Responsibilities:-

To comprehensively assess patients with complex physical, mental and social care needs using advanced clinical examination skills, detailed history taking and biometric monitoring and evaluation skills.

To have an understanding of the combined impact of all of the patients conditions on their health and social care needs in order to improve health outcomes and quality of life.

Develop individualised treatment and management plans using evidence based practice and proactively monitor patients and review care plans.

To use advanced skills and expert knowledge to identify subtle changes in condition and take appropriate action.

To identify and plan preventative measures and anticipatory care needs.

To maintain accurate, contemporaneous, and comprehensive records of care, using recording systems used within the HVS.

To review medications with patient presentations, discussing changes with the GP in accordance with national and local guidance.

To make direct referrals on to other services or professions, discuss diagnostic tests and instigate treatments and interventions as required working collaboratively with the GP.

To analyse signs and symptoms, laboratory tests and other measures of function, in formulating a diagnosis

To work as an autonomous practitioner, managing and prioritising own caseload, through clinical judgement, according to local and national guidelines and identified need.

To work in a variety of settings, exercising a high level of judgement, discretion and decision making in clinical care.

To continuously review practice and participate in implementing change as appropriate and defined within the organisation policy

To work according to the NMC Code of Conduct and professional practice and the relevant legislative framework and exercise professional accountability at all times

To be responsible for keeping professionally updated and registered with the NMC

To use advanced skills and expert knowledge to perform a comprehensive assessment of physical, mental health and social care needs that addresses the combined impact of all of the patients conditions in order to improve health outcomes and quality of life

To manage multiple chronic diseases, cognitive and functional impairment.

To identify and plan preventative measures and anticipatory care needs in accordance with patient presentation and care needs

To proactively monitor patients and review care plan whilst on the HVS using an MDT approach.

Support Self-Management of Long Term Conditions:-

To work in collaboration with patients and carers, identifying self-management needs and increase their knowledge of their condition, in order that they develop skills to manage their condition effectively.

To provide the necessary tools and equipment to patients so that they can monitor their condition, identify warning signs of complications and crisis and know when to call for support.

To support self-management programmes.

To provide information to patients, their carers and families so they can make informed choices about current and future care needs.

To prepare the patient and their family for changes in condition and support choice for end of life care working in partnership with the community nursing services to optimise care.

Care Co-ordination and Cross Organisational Work:-

To work in collaboration with the Primary Health Care Team including all health, social care and voluntary agencies to provide care for patients and their families and informal carers in their own home, within given resources.

To work in partnership on the development, management and ongoing review of the care plan with the patients GP, specialists, pharmacists, social care and other services and professions as required.

To prioritise and coordinate the multiple health care needs of the patient.

To negotiate and agree with patient, informal carer/family and other care professionals, individual roles, and responsibilities with actions to be taken and outcomes to be achieved, referring on to other services or professions as appropriate.

Maintain responsibility for the patients pathway throughout all components of the health and social care system to prevent duplication, and delays in care. To manage the care of the patient whilst active on the HVS caseload and handover care to other services as appropriate.

Communication:-

To establish and maintain effective communication and liaison with the Primary Health Care Team and other agencies involved in caring for patients in the Community i.e. voluntary and statutory agencies, relatives and carers.

To communicate in a professional and sensitive manner with people, their relatives and carers taking into consideration their need for dignity, privacy and independence as well as their cultural and spiritual values.

To communicate to a variety of forums the role of the HVS Specialist Nurse.

To effectively communicate at all levels of the organisation; to a variety of health and social care professionals working in primary, community and secondary care, out of hours providers, voluntary organisations and patients and carers..

To maintain accurate and up-to-date patient records, informing other professionals about changes in the patients condition where appropriate.

To provide high quality written reports and any other written documentation as necessary.

To act as advocate for the patient as required to ensure their individual needs, preferences and choices are delivered.

Service Development:-

To develop systems for auditing in order to determine standards of practice and use research awareness skills to critically appraise the effectiveness of practice.

To submit statistical and contractual monitoring returns within agreed time scales.

To participate in the development, implementation and evaluation of protocols, guidelines, policies, integrated care pathways and tools.

To participate in the evaluation regarding the process, outcomes and impact of the HVS and to help develop service delivery across the South Kent Coast area.

To act as a change agent and innovator and lead on the development of new systems and ways of working across the whole system to meet the needs of people with complex multiple long term needs.

To provide support to newly recruited to HVS team members.

Education, Training and Development:-

To provide education and training for other staff and students including pre- and post- registration nursing students

To access appropriate and relevant training opportunities that will enhance both personal and professional development

Qualifications

Essential

• GCSE Grade A - C in English and Maths
• RGN
• 1st Level Degree
• Full Driving licence

Desirable

• Leadership/Teaching qualification
• Nurse Independent and Supplementary Prescribing Qualification
• Evidence of continual professional development

Knowledge, Skills and Abilities.

Essential

• Case Management skills, or willingness to develop
• Clinical examination skills, physical examination and assessment skills (top to toe assessment), detailed medical history skills, biometric monitoring and evaluation skills, or willingness to develop
• Health coaching skills, or willingness to develop
• Excellent organisational skills
• Ability to prioritise and co-ordinate workload
• Excellent leadership skills
• Excellent problem solving skills to identify and resolve clinical and whole system issues
• Ability to interpret and analyse complex data from numerous sources to inform decisions
• Highly developed interpersonal and communication skills
• Ability to effectively delegate activities to appropriate staff
• Ability to effectively negotiate on patient management
• Ability to engage and develop partnership working with all those involved in the management of long- term conditions
• Ability to work as a member of a team
• Ability to work unsupervised and manage own caseload
• Ability to make clinical and administrative decisions
• Ability to be goal and outcome focused when faced with opposition or when working under conditions of pressure
• Ability to use IM&T support systems
• Ability to translate best practice evidence and national policy into practice
• Knowledge of national service frameworks and the national long-term conditions policy
• Additional Requirements
• Ability to travel to multiple sites
• Clean driving license with access to a fully insured car.

Desirable

• Basic IT skills

Experience

Essential

• Post registration experience in assessing and planning care for patients with a wide range of acute and chronic illnesses.

Desirable

• Experience of working in a variety of settings (hospital, primary and community)
• Experience of leading change
• Management experience
• Experience of working as a change agent to improve patient care.

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).