Job summary
An opportunity has arisen for a Community Matron to lead and line manage our friendly and professional Frail Elderly case management team in Ketts Oak PCN.
The team provide advanced case management and clinical nursing care to patients with long term conditions who are often high intensity users of both primary and secondary care. You will work closely with PCN and NCHC community team colleagues to assess and provide advanced level interventions for patients with long term conditions to achieve quality of life and independence where possible.
Main duties of the job
- To be responsible for the day-to-day operational line management of the Frail Elderly Team
- To assess & provide advanced level interventions for patients with long term conditions to achieve quality of life & independence where possible
- To work within the integrated team & case managers to facilitate early discharge from hospital
- To work within the integrated team to prevent unnecessary admission to hospital
- To work with all health care professionals, & statutory/non statutory agencies to provide a seamless, integrated service
- To facilitate & develop a service providing complex case management.
- To proactively case find patients who are very high intensity users of primary & secondary healthcare & / or are at high risk of unplanned admission to hospital
- To educate & support members of the multi-disciplinary team to intensively case manage these patients
- To intensively case manage own caseload of patients with highly complex and unstable health needs
- Develop systems & processes to support intensive case management within the multi-disciplinary team & with partners across the health system
- Work with & refer appropriately to other agencies to enable identified patients to be intensively managed in a pro-active way with the aim of preventing hospital admission, supporting early discharge & reduce GP contact
- Be accountable for the intensive case management & where appropriate intervention of a defined patient caseload
- Be a champion for people with long term conditions
About us
Norfolk Community Health & Care NHS Trust provides community-based NHS health and care via more than 70 locations across Norfolk,
We believe that people are better looked after locally & this belief drives us to work hard to bring expert care to patients in our community hospitals, within GP surgeries & in patients' own homes. Working in the community will provide you with the opportunity to develop longer-term & more personal relationships with patients, carers & other professionals.
NCH&C is proud to be the first standalone NHS community trust in the UK to achieve an 'Outstanding' rating from the Care Quality Commission (CQC). Our focus is on continually improving the quality of care we offer to local people & improving access to that care, helping people to move seamlessly from one service to another.
NCH&C is committed to continuing to create a modern and inclusive work environment. As part of this commitment we actively promote flexible working opportunities where possible, to meet the needs and wishes of our workforce to maintain and improve their wellbeing. The trust offers a range of flexibility, including flexible working patterns, and we would encourage you to discuss this with the recruiting manager before or during the application process if this would interest you.
Job description
Job responsibilities
Key Areas of Responsibility
- To be responsible for the day-to-day operational line management of the Frail Elderly Team of case managers
- To assess and provide advanced level interventions for patients with long term conditions to achieve quality of life and independence where possible.
- To work within the integrated team and case managers to facilitate early discharge from hospital
- To work within the integrated team and case managers to prevent unnecessary admission to hospital
- To work with all health care professionals, and statutory/non statutory agencies to provide a seamless, integrated service to our service users.
- To facilitate and develop a service providing complex case management.
- To proactively case find patients who are very high intensity users of primary and secondary healthcare and / or are at high risk of unplanned admission to hospital.
- To educate and support the members of the multi-disciplinary teams to intensively case manage these patients.
- To intensively case manage their own caseload of patients with highly complex and unstable health needs.
- Develop systems and processes to support intensive case management within the multi-disciplinary team and with partners across the health system.
- Work with and refer appropriately to other agencies to enable identified patients to be intensively managed in a pro-active way with the aim of preventing hospital admission, supporting early discharge and reduce GP contact.
- Be accountable for the intensive case management and where appropriate intervention of a defined patient caseload.
- Case finding to actively work with GPs and other agencies, and with appropriate information technology, such as PARR ++, to case find patients.
- Be a champion for people with long term conditions.
Clinical Practice
- Using expert knowledge, advanced clinical and autonomous decision-making skills, intensively case manage patients with highly complex and unstable health needs.
- Comprehensively assess, review and evaluate the needs of both patients and their carers to improve their physical and psychological well-being whilst reducing acute exacerbation of underlying conditions and need for hospitalisation.
- Work in partnership with patients, carers, GPs, consultants, other health professionals and social care as appropriate, to instigate diagnostic testing and therapeutic treatments to ascertain diagnosis and implement proactive treatment and care plans.
- Use prescribing skills and knowledge of medicines to minimise the risk and complications associated with medication and polypharmacy.
- Maintain contact with patients who are admitted to hospital, ensuring the team providing inpatient care have the most up-to-date and relevant information and help facilitate discharge as soon as the acute treatment phase is complete.
- To work with the MDT in the development, implementation and evaluation of policies, protocols and guidelines.
- Provide clinical nurse leadership and support to other staff, enabling their own ongoing professional development and understanding of service provided.
- Develop care plans with patients involving others, e.g. carers, advocates etc. to ensure best outcomes for patients, focussing on their ability to function and their quality of life.
- To communicate complex patient information effectively to ensure collaborative working.
Leadership
- Facilitate development of the team and individual staff members to promote job satisfaction, performance and an ability to manage change
- To plan, co-ordinate and evaluate the service to ensure they are safe, efficient and effective with regard to patient management and use of staff time.
- Be responsible for the compliance of Mandatory training and appraisals within the team, ensuring KPIs are achieved.
- Be an authorised signatory for goods, services and payroll.
- Accurately complete personal human resources documentation in respect of team members, ensuring designated time frames are adhered to.
- Monitor and manage the team budget and assist senior management to effectively manage resources.
- Monitor and manage staff absence, annual leave and study leave in line with NCHCs policies, procedures and guidelines.
- Be actively involved with disciplinary and complaints procedures where appropriate and managing investigation of incidents.
- Establish clinical credibility within the multi-disciplinary team and act as a role model for clinical excellence.
- Work collaboratively with other case managers and other members of the multidisciplinary team to lead developments in professional practice and to support multidisciplinary working around the needs of very high intensity users and those at high risk of hospital admission.
- Use effective communication, negotiating and influencing skills to introduce new systems of working to improve the pathway of patients who are very high intensity users of health care and / or at high risk of hospital admission.
- Provide high quality reports and data on clinical activity.
- Encourage and support innovation, sharing of expertise and new ways of working within the multi-disciplinary team to meet the needs of patients.
- Be aware of Trusts behaviour framework and ensure behaviours are embedded in role.
- Ensure Trusts behaviour framework is utilised when managing and supervising staff, and that behaviours are embraced and embedded within the team.
Education
- Champion the role and value of case finding an intensive case management at all levels of the organisation and across all professional groups.
- Continually audit and evaluate the quality and effectiveness of clinical practice within intensive case management, selecting and applying a wide range of valid and reliable approaches and methods that are appropriate to the need and context.
- Contribute to the wider development of practice by participating in research, audit, local and national presentations, networks and publication as appropriate.
- Develop, implement and evaluate educational programmes for workers in primary and community services to provide the necessary knowledge and skills for effective case management of patients with long term conditions and at high risk of hospital admission.
- Educate and empower patients and carers to identify early signs of change in condition and provide them with the necessary knowledge and skills to gain independence and make informed choices to safely manage their condition
Job description
Job responsibilities
Key Areas of Responsibility
- To be responsible for the day-to-day operational line management of the Frail Elderly Team of case managers
- To assess and provide advanced level interventions for patients with long term conditions to achieve quality of life and independence where possible.
- To work within the integrated team and case managers to facilitate early discharge from hospital
- To work within the integrated team and case managers to prevent unnecessary admission to hospital
- To work with all health care professionals, and statutory/non statutory agencies to provide a seamless, integrated service to our service users.
- To facilitate and develop a service providing complex case management.
- To proactively case find patients who are very high intensity users of primary and secondary healthcare and / or are at high risk of unplanned admission to hospital.
- To educate and support the members of the multi-disciplinary teams to intensively case manage these patients.
- To intensively case manage their own caseload of patients with highly complex and unstable health needs.
- Develop systems and processes to support intensive case management within the multi-disciplinary team and with partners across the health system.
- Work with and refer appropriately to other agencies to enable identified patients to be intensively managed in a pro-active way with the aim of preventing hospital admission, supporting early discharge and reduce GP contact.
- Be accountable for the intensive case management and where appropriate intervention of a defined patient caseload.
- Case finding to actively work with GPs and other agencies, and with appropriate information technology, such as PARR ++, to case find patients.
- Be a champion for people with long term conditions.
Clinical Practice
- Using expert knowledge, advanced clinical and autonomous decision-making skills, intensively case manage patients with highly complex and unstable health needs.
- Comprehensively assess, review and evaluate the needs of both patients and their carers to improve their physical and psychological well-being whilst reducing acute exacerbation of underlying conditions and need for hospitalisation.
- Work in partnership with patients, carers, GPs, consultants, other health professionals and social care as appropriate, to instigate diagnostic testing and therapeutic treatments to ascertain diagnosis and implement proactive treatment and care plans.
- Use prescribing skills and knowledge of medicines to minimise the risk and complications associated with medication and polypharmacy.
- Maintain contact with patients who are admitted to hospital, ensuring the team providing inpatient care have the most up-to-date and relevant information and help facilitate discharge as soon as the acute treatment phase is complete.
- To work with the MDT in the development, implementation and evaluation of policies, protocols and guidelines.
- Provide clinical nurse leadership and support to other staff, enabling their own ongoing professional development and understanding of service provided.
- Develop care plans with patients involving others, e.g. carers, advocates etc. to ensure best outcomes for patients, focussing on their ability to function and their quality of life.
- To communicate complex patient information effectively to ensure collaborative working.
Leadership
- Facilitate development of the team and individual staff members to promote job satisfaction, performance and an ability to manage change
- To plan, co-ordinate and evaluate the service to ensure they are safe, efficient and effective with regard to patient management and use of staff time.
- Be responsible for the compliance of Mandatory training and appraisals within the team, ensuring KPIs are achieved.
- Be an authorised signatory for goods, services and payroll.
- Accurately complete personal human resources documentation in respect of team members, ensuring designated time frames are adhered to.
- Monitor and manage the team budget and assist senior management to effectively manage resources.
- Monitor and manage staff absence, annual leave and study leave in line with NCHCs policies, procedures and guidelines.
- Be actively involved with disciplinary and complaints procedures where appropriate and managing investigation of incidents.
- Establish clinical credibility within the multi-disciplinary team and act as a role model for clinical excellence.
- Work collaboratively with other case managers and other members of the multidisciplinary team to lead developments in professional practice and to support multidisciplinary working around the needs of very high intensity users and those at high risk of hospital admission.
- Use effective communication, negotiating and influencing skills to introduce new systems of working to improve the pathway of patients who are very high intensity users of health care and / or at high risk of hospital admission.
- Provide high quality reports and data on clinical activity.
- Encourage and support innovation, sharing of expertise and new ways of working within the multi-disciplinary team to meet the needs of patients.
- Be aware of Trusts behaviour framework and ensure behaviours are embedded in role.
- Ensure Trusts behaviour framework is utilised when managing and supervising staff, and that behaviours are embraced and embedded within the team.
Education
- Champion the role and value of case finding an intensive case management at all levels of the organisation and across all professional groups.
- Continually audit and evaluate the quality and effectiveness of clinical practice within intensive case management, selecting and applying a wide range of valid and reliable approaches and methods that are appropriate to the need and context.
- Contribute to the wider development of practice by participating in research, audit, local and national presentations, networks and publication as appropriate.
- Develop, implement and evaluate educational programmes for workers in primary and community services to provide the necessary knowledge and skills for effective case management of patients with long term conditions and at high risk of hospital admission.
- Educate and empower patients and carers to identify early signs of change in condition and provide them with the necessary knowledge and skills to gain independence and make informed choices to safely manage their condition
Person Specification
Qualifications
Essential
- oRegistered General Nurse and current NMC registration
- o1st level degree or currently on degree pathway
- oEvidence of continuing professional development and its application
- oEvidence of specialist clinical expertise within a relevant area such as COPD, Heart Failure
Desirable
- Masters degree incorporating Advanced Clinical Practice and Independent Prescribing (or willingness to undertake)
- Line management experience
Experience
Essential
- oPost qualification experience including previous experience at least at a Band 6 level
- oExperience of multi- disciplinary and partnership working in acute and community settings
- oAdvanced understanding of clinical conditions and clinical experience in managing long term conditions
- oImplementing change
- oClinical supervisor
Skills. Ability / Knowledge
Essential
- oBroad range of clinical skills
- oAn understanding of intensive case management and systems for case finding
- oAbility to influence and motivate staff at all levels
- oCompetent in use of IT
- oAble to communicate effectively in the English language in both written and verbal formats.
Qualities and attributes
Essential
- Demonstrates strong leadership skills
- Demonstrates excellent interpersonal, communication and negotiation skills
- Evidence of strong interdisciplinary and multiagency team working
- Innovative
- Committed
- Ability to work autonomously and to use initiative
Other
Essential
- Ability to make own travel arrangements
Person Specification
Qualifications
Essential
- oRegistered General Nurse and current NMC registration
- o1st level degree or currently on degree pathway
- oEvidence of continuing professional development and its application
- oEvidence of specialist clinical expertise within a relevant area such as COPD, Heart Failure
Desirable
- Masters degree incorporating Advanced Clinical Practice and Independent Prescribing (or willingness to undertake)
- Line management experience
Experience
Essential
- oPost qualification experience including previous experience at least at a Band 6 level
- oExperience of multi- disciplinary and partnership working in acute and community settings
- oAdvanced understanding of clinical conditions and clinical experience in managing long term conditions
- oImplementing change
- oClinical supervisor
Skills. Ability / Knowledge
Essential
- oBroad range of clinical skills
- oAn understanding of intensive case management and systems for case finding
- oAbility to influence and motivate staff at all levels
- oCompetent in use of IT
- oAble to communicate effectively in the English language in both written and verbal formats.
Qualities and attributes
Essential
- Demonstrates strong leadership skills
- Demonstrates excellent interpersonal, communication and negotiation skills
- Evidence of strong interdisciplinary and multiagency team working
- Innovative
- Committed
- Ability to work autonomously and to use initiative
Other
Essential
- Ability to make own travel arrangements
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
