Care Home Care Planning Practitioner

Job responsibilities

The postholder will support the ongoing implementation of integrated neighbourhood teams and MDT working in care homes across the Royal Borough of Kingston.

The postholder will support the implementation, management and delivery of enhanced MDT working in care homes across Kingston.

Care homes are supported by professionals from many different services, the postholder will work in partnership with care homes, Care Home (GP) Leads, acute and community services to deliver enhanced MDT working and increase the use of the Universal Care Plan.

The postholder will collaborate with professionals to initiate care planning discussions including advance care planning, comprehensive geriatric assessment, frailty and dementia to initiate and complete a universal care plan.

This enhanced approach to MDT working and care planning aims to improve the use of the health and care system by intervening earlier, proactively and more holistically for residents of care homes.

The postholder will support primary and community care to effectively deliver, implement and evaluate changes to ways of working.

Dimensions

• Work in collaboration with Health Care Professionals supporting care home residents and to identify those at risk of deterioration, deconditioning or admission for discussion with the MDT, initiate or review of advance care plans through the UCP.

• Participate in MDT meetings to help residents to navigate community and specialist services.
• Challenge professional and organisational boundaries which prevent delivery of integrated health and social care to prevent health deterioration or hospital admission
• Establish a network that can be used to streamline care pathways, working in partnership with other agencies
• Ensure effective co-ordination of care for individual residents within the care home setting
• Link in with the care homes on a regular basis directly to ensure awareness of any new residents, discharges, deaths or hospital admissions etc.
• Ensure care homes provide baseline health data if the resident is admitted to hospital to support integrated, consistent care and facilitate discharge
• Work with the multi-disciplinary team to plan and implement high quality care.
• Identifying patients who have complex care needs, formulating appropriate management plans and support care home staff with following management plans
• To participate in working with care home staff to identify and manage residents with complex or long-term conditions, prevent admission to hospital and advising on nursing intervention to avoid deterioration.
• Attend regular ward rounds with clinical leads from GP practices
• Attend PCN Pharmacy meetings to ensure that the Clinical Pharmacists are aware of any new residents so that they can facilitate an SMR.

Communication

• Use a high level of interpersonal, IT and communication skills to communicate effectively with residents and care home staff, including communication of sensitive and complex information about individual condition.
• Use a high level of interpersonal, IT and communication skills to communicate effectively with residents and care home staff, including communication of sensitive and complex information about individual condition.

• Effectively communicate at all levels of the organisation with a variety of health professionals, users and carers to provide the best health and social care outcomes for older people.
• Provide the interface between hospital and Primary, Community & Social Care and Care Home settings.
• Maintain a high level of performance and be goal and outcome focussed when faced with opposition or when working under conditions of pressure.
• Keep accurate timely documentation.
• Provide high quality written reports and any other written documentation as necessary.
• Listen and empathise with the needs and wishes of users and their carers
• Monitor hospital admissions A&E attendance & ambulance call rates for care homes in the Kingston borough liaising with KHFT Transfer of Care Hub, Discharge Coordinators and other key personnel to enable proactive working and provision of targeted support to facilitate earlier discharge and prevent unnecessary admission to hospital for care home residents.
• Support care homes, linked G.Ps and Adult Services to work collaboratively to achieve effective communication and provision of proactive medical/nursing/therapeutic care to facilitate earlier discharge and prevent unnecessary hospital admissions.
• Collect data as required supporting audit focusing on health outcomes and reduction of acute hospital emergency bed days.

Key Responsibilities

• Support GPs with their weekly ward round, proactively identifying residents who need attention and support care home staff to update Universal Care Plans as appropriate.
• Challenge professional and organisational boundaries which prevent delivery of integrated health and social care to prevent health deterioration or hospital admission.
• Support the Urgent Care & Support Service with case managing patients with exacerbation of long-term conditions/complex conditions, enabling care homes to prevent crisis situations arising, thereby avoiding inappropriate hospital admissions.
• Support and develop a process of a seamless transfer of care between hospitals, care homes and community to ensure continuity of care.
• Support the care homes in developing Universal care plans (UCP) and crisis management plans with residents carers, relatives and health professionals based on full assessment of medical, nursing and social care needs
• Support care homes with Advanced Care Planning, DNAR, Assessment of symptoms prescribing of EoL drugs and verification of death.
• Empower care home staff in nursing homes to engage in difficult conversations with residents and families to facilitate Advance Care Planning.
• Work in partnership with GPs, co-ordinating the seamless transfer of residents to appropriate services.
• Be a point of contact for care home staff and professionals who visit the care home, such as GPs and in-reach specialists.

Line Management

• To ensure the smooth and efficient running of the service in partnership with the Advanced Nurse Practitioner/Urgent care & support service lead, the overall strategic direction and development of the Service.
• To participate in the development and integration of care pathways, policies and procedures that will influence service delivery and practice.

Researcher

• Evaluation of the project particularly in relation to impact
• Identifying the population at risk within the care homes using local data and information from a variety of sources.
• Critically evaluate and interpret evidence-based research finding from diverse sources making informed judgements about their implications for changing and/or developing services and clinical practice.
• To support the Urgent care & support service to evaluate and audit the quality and effectiveness of the practice of self and others, selecting and applying a wide range of valid and reliable approaches and methods that are appropriate to needs and context.

Experience

Essential

• Negotiating and working across organisational boundaries
• Working as part of a multi-disciplinary team
• Mentoring students and other health care professionals
• Experience of lone working and decision making
• Experience of completing Advanced Care Plans and End of Life care to patients

Desirable

• Experience of working in care homes
• Experience of working in a community setting for a minimum of 3 years post registration and community experience of assessment and delivery of care to people with complex needs

Personal Qualities

Essential

• Able to work under pressure
• Self-motivated
• Able to motivate others
• Innovative
• Enthusiastic
• Able to work alone

Other factors

Essential

• Valid driving license
• Must be a car driver and have use of car for business use

Knowledge

Essential

• Knowledge of NMC Code
• Knowledge of Advance Care Plans/Universal Care plans
• Understanding of national policy governing the delivery of adults and older peoples services
• Awareness of current developments in health and social care
• Knowledge of clinical governance/ risk management and reporting
• An understanding of the implications of cultural difference for service delivery
• Knowledge and understanding of audit and research

Desirable

• Awareness of issues surrounding care homes

Skills & Abilities

Essential

• Evidence of up-to-date based knowledge and skill
• Evidence of ability to maintain high standards of care
• Evidence of professional development and knowledge
• Able to analyse situations and problem solve as necessary
• Ability to develop and maintain partnership working
• Ability to motivate staff
• Report writing skills
• IT Skills

Qualifications

Essential

• Registered Level 1 Nurse
• Diploma/Degree in nursing studies
• Evidence of Continuing Professional Development

Desirable

• V300 Independent Prescriber

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).