Community Matron

Job responsibilities

Maximise independence by supporting people with long term conditions and highly complex needs to remain in their own homes as appropriate, by utilising and commissioning available resources.

Undertake clinical assessment and diagnosis and provide treatment for patients within the defined group.

Link with existing services to facilitate early discharge from hospital and prevent re-admission.

Develop Partnerships and joint working within the local health and social care economy.

Work collaboratively across organisation boundaries to support the effective and co-ordinated provision of social care and health care services.

CLINICAL REQUIREMENTS:

Conduct a comprehensive health and social care assessment, utilising any current information in order to develop an individualised plan of care for patients within a defined group. This will include:

• Review of health assessment including medical history
• Physical examination
• Assessment and review of medication
• Prescribing in conjunction with management plans
• Making referrals for diagnostic tests
• Functional /cognitive assessment
• Assessment of social care needs

Develop, monitor and manage the plan of care in collaboration with the primary health and social care team and others through:

• Application of clinical knowledge about long term conditions
• Analysis of symptoms and data
• Identification of risk factors associated with exacerbation of patients condition
• Recognition and management of early signs and symptoms of acute illness.
• Involving patients and carers in the development of the care plan and ensuring that their views and abilities are reflected.
• Documentation of progress and continuous reassessment
• Referral and investigation

To be responsible for maintaining competence in clinical and diagnostic skills required to manage patients

Set up and actively participates in case review to evaluate the outcomes of care plans including social care needs

Co-ordinate care and treatment to avoid fragmentation, duplication and delay, in the least intensive setting appropriate to the patients needs by:

• Prioritisation and co-ordination of multiple health and social care needs
• Referrals to specialist services
• Ensuring effective communication and sharing of appropriate information amongst professionals to avoid conflicting treatments.
• Integration across health and social care (inc. voluntary sector and housing)
• Identifying deficiencies in service provision and addressing these as appropriate (i.e. through commissioning services for individuals)
• Understanding and working through entitlements to social care and necessary financial assessments

Be aware of and adhere to, the Professional bodies Standards for administration of Medicines Act 1992, and the Misuse of Drugs Act 1971.

LEADERSHIP REQUIREMENTS

Lead the process of identifying their caseload through interpretation of the information available on the health needs of the locality in which they are based and contribute to the collection of data to monitor outcomes measures for the caseload

Participate in the development of case management across the Trust

Provide clinical leadership and mentoring to those staff developing into a case management role

Make, implement and communicate changes to clinical practice as necessary in relation to case management

Challenge professional and organisational boundaries to ensure that the Case Management role is focused on meeting the needs of service users, thus promoting continuity of high quality patient centred health and social care.

Acts as an advocate and champion for patients in a variety of forums and professional groups and challenges attitudes and behaviour.

Act as a role model so that patients receive the most effective care possible through:

• Encouraging optimum management of long term conditions to ensure that the patient is functioning at the most independent level possible
• Acting in patients interests at all times

Contributing to the development of policy and services to reflect the needs of the patient caseload.

MANAGERIAL RESPONSIBILITIES

Manage the complex clinical and social care interventions of individuals within an identified patient group on an ongoing basis.

Undertake risk assessment in relation to individuals within the client group

Monitor and respond to the development of changing clinical and social situations with the identified patient group without recourse to others where possible

Ensure the safe management of care and service delivery

Line manage a defined team of staff; including performing appraisal, personal development reviews and the application of staff management procedures

SERVICE DEVELOPMENT REQUIREMENTS

Encourage patient and carer participation in case management through:

• The provision of information about disease prevention, progression and outcomes.
• Ensuring that services are accessible to increase patient confidence
• Empowering the patient to self-manage whenever possible.

Contribute to the development of role and service redesign in long term condition management.

To provide clinical leadership for the development of the urgent care agenda

ANALYTICAL AND INFORMATION REQUIREMENTS

The post holder will utilise data and data tools (including databases) to produce appropriate monitoring reports on both patient care and service outcomes and produce appropriate communication for patients

CLINICAL GOVERNANCE REQUIREMENTS

Participate in individual and group clinical supervision and action learning sets, and to take responsibility for developing own learning.

Participate in research and audit relating to long term conditions management.

Ensure systems are in place for on-going review and assessment of care provision and delivery.

Improve quality via Clinical Governance, and Clinical Supervision, by working closely with colleagues to address competency levels within the service.

Report any incidents through application of trust policies.

Participate in patient satisfaction reporting to improve patient care.

EDUCATION AND DEVELOPMENT

Promote formal and informal training to pre and post registration health and social care professionals in relation to integrated working and provide mentorship and teaching to others developing a case management function.

Participate in the induction of new staff.

Provide education, advice and support to health and social care staff, people with long term conditions and their carers; in both community and acute settings.

Maintain up to date knowledge and competence in line with professional and service requirements and demonstrate critical thinking, decision making and reflective skills to ensure own professional development.

COMMUNICATION/RELATIONSHIP REQUIREMENTS

Liaise with patients and carers, community and specialist nursing and other health professionals, GPs, acute colleagues, social care colleagues and the voluntary/charitable and non-NHS sector.

Work with patients and carers to:

• Ensure that their values, beliefs and views are reflected in the case management plan
• Encourage active participation in case management
• Ensure that health advice and social care is provided in a professional, accessible and supportive way.

Work with other professional and statutory groups involved in case management to:

• Ensure that there is consistent and high quality implementation of care
• Avoid duplication, delay or distress to patient
• Ensure that record keeping is consistent with Trust and Professional standards.

Communicate at all levels of the organisation to a variety of health and social care professionals to provide best outcomes for patients.

LEVEL OF INDEPENDENCE/FREEDOM TO ACT

The post holder is required to execute the duties of this role without reference to others. This includes undertaking an advanced level of clinical assessment, the application of critical thinking, high level decision making and the delivery of specialist care and treatment.

The post holder is expected to abide by their professional code of conduct when exercising autonomy and to safeguard the interests of patients.

HEALTH AND SAFETY

In accordance with the Health and Safety at Work Act 1974 and other supplementary legislation, you are required to take reasonable care to avoid injury during the course of work and co-operate with Trust and others in meeting statutory regulation. You are also required to attend statutory training as required to fulfil your duties.

To comply with safety instructions and Trust policies and procedures.

To use in a proper and safe manner, the equipment and facilities provided.

To refrain from wilful misuse of, or interface with, anything provided in the interest of health and safety and any action, which might endanger yourself and others.

To report as soon as practical, any hazards and defects to your senior manager.

To report as soon as practical, accidents and untoward incidents and to ensure accident forms are completed.

Qualifications

Essential

• Relevant Clinical Professional Qualification
• Degree or equivalent clinical/advanced practice
• Extensive post registration experience
• Management/Clinical Leadership experience
• Clinical Master's Degree or working towards/ or current masters study
• Prescribing qualification at V300
• Evidence of post registration/qualification

Knowledge/Experience

Essential

• Experience of working with patients with long term conditions
• Experience of successful multi agency working - including an understanding/ experience of working in a social care environment
• Evidence of influencing, motivating and negotiating with others to achieve change in relation to care
• Experience of initiating and implementing and developing clinical care/protocols.
• Experience of practising advanced clinical skills
• Understanding of the principles of case management
• Awareness of long term condition management agenda
• Awareness of current national and local agenda in health and social care
• Understanding of how other agencies work (i.e. housing, social services, the independent sector etc)
• Evidence of being able to communicate complex information and advice on healthcare to patients/carers and colleagues
• Ability to work under pressure and manage a diverse work load
• Proficient IT skills
• Excellent interpersonal skills; including negotiation, influencing and presentation
• Risk Assessment skills
• Ability to understand and analyse complex data
• Self-management and motivation skills
• Confidence to challenge traditional practice and Awareness of factors which contribute to good health and the importance of promoting these in line with organisational public health policy

Values

Essential

• Continuous Improvement
• Accountability
• Respectfulness
• Enthusiasm
• Support
• High professional standards
• Responsive to service users
• Engaging leadership style
• Strong customer service belief
• Transparency and honesty
• Discreet
• Change oriented

Skills

Essential

• Rehabilitation nursing and social care assessment skills
• Moving and handling skills (including ability to assess need)
• Clinical decision making
• Venepuncture
• Palliative/end of life care skills
• Clinical Assessment skills* (Clinical Masters level or equivalent for example; history taking, physical examination, ordering and review of blood tests and the ability to investigate and diagnose an unwell person etc.)
• Working knowledge of Cognitive function and its effect
• The ability to travel across the Trust
• The ability to work flexibly in accordance with service needs
• Ability to undertake physical 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).