Job summary
To provide advanced intensive case management and clinical nursing care to patients with long term conditions who are high intensity users of both primary and secondary care. To visit and assess patient to prevent admission to hospital.
Main duties of the job
An exciting opportunity has arisen for an experienced clinical nurse as a Community Matron to work within the Kings Lynn or Coastal PCN's.
This rewarding post will be aligned to General Practice and the successful candidate will work very closely with GP's to identify and case manage complex patients to enhance the patient's health and quality of life. Through this process the aim is to avoid unnecessary hospital admissions and where patients have been hospitalised, to facilitate an early discharge.
Close collaboration with other Health and Social Care Services is an essential part of this role and the successful candidate will need to have excellent communication skills and an ability to organise and prioritise their caseload according to the needs of their patient's and the service.
Enquiries Welcomed.
About us
Apply now to join an organisation that has been awarded an 'Outstanding' rating by the Care Quality Commission (CQC), the highest possible rating and the first stand-alone NHS community trust in the country to be awarded the title.
Job description
Job responsibilities
- 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 provide a weekend on-call telephone support service between 8am and 5pm.
- 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.
- The post holder will practise as a non-medical prescriber in accordance with the Trusts non-medical prescribing policy, protocols, national policies, and within ones scope of competency.
Job description
Job responsibilities
- 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 provide a weekend on-call telephone support service between 8am and 5pm.
- 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.
- The post holder will practise as a non-medical prescriber in accordance with the Trusts non-medical prescribing policy, protocols, national policies, and within ones scope of competency.
Person Specification
Qualifications
Essential
- RGN and current NMC registration
- 1st Level degree
- Evidence of continuing professional development and its application
- Advanced assessment skills
Desirable
- Evidence of specialist clinical expertise within a relevant area such as COPD, Heart Failure
- Masters Degree incorporating Advanced Clinical Practice and Independent Prescribing (or willingness to undertake)
Other
Essential
- Must hold a full and valid driving licence and have access to a vehicle
Experience
Essential
- Post qualification experience including previous experience at a relevant level
- Experience of multidisciplinary and partnership working in acute and community settings
- Advanced understanding of clinical conditions and clinical experience in managing long-term conditions
- Implementing change
- Clinical Supervisor
Desirable
- Teaching in Clinical Practice
- Contribution to service planning
- Experience of audit
Skills, Abilities and Knowledge
Essential
- Broad range of clinical skills
- An understanding of wider NHS and social care issues
- An understanding of intensive case management and systems for case finding
- Ability to influence and motivate staff at all levels
- Effective presentation skills
- Competent in use of IT
- Ability to prioritise and work to deadlines
Desirable
- Ability to use and interpret information and demonstrate this in supporting evidence for this post
Personal Attributes/Behaviours
Essential
- Demonstrates strong leadership skills
- Demonstrates excellent interpersonal, communication and negotiation skills
- Evidence of strong interdisciplinary and multiagency team working
- Innovative
- Flexible and committed
- Ability to work autonomously and to use initiative
Desirable
- Able to identify with the Trust's Vision and evidence of involvement with change Management
Person Specification
Qualifications
Essential
- RGN and current NMC registration
- 1st Level degree
- Evidence of continuing professional development and its application
- Advanced assessment skills
Desirable
- Evidence of specialist clinical expertise within a relevant area such as COPD, Heart Failure
- Masters Degree incorporating Advanced Clinical Practice and Independent Prescribing (or willingness to undertake)
Other
Essential
- Must hold a full and valid driving licence and have access to a vehicle
Experience
Essential
- Post qualification experience including previous experience at a relevant level
- Experience of multidisciplinary and partnership working in acute and community settings
- Advanced understanding of clinical conditions and clinical experience in managing long-term conditions
- Implementing change
- Clinical Supervisor
Desirable
- Teaching in Clinical Practice
- Contribution to service planning
- Experience of audit
Skills, Abilities and Knowledge
Essential
- Broad range of clinical skills
- An understanding of wider NHS and social care issues
- An understanding of intensive case management and systems for case finding
- Ability to influence and motivate staff at all levels
- Effective presentation skills
- Competent in use of IT
- Ability to prioritise and work to deadlines
Desirable
- Ability to use and interpret information and demonstrate this in supporting evidence for this post
Personal Attributes/Behaviours
Essential
- Demonstrates strong leadership skills
- Demonstrates excellent interpersonal, communication and negotiation skills
- Evidence of strong interdisciplinary and multiagency team working
- Innovative
- Flexible and committed
- Ability to work autonomously and to use initiative
Desirable
- Able to identify with the Trust's Vision and evidence of involvement with change Management
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
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).
