Integrated Community Support Team Nurse

Job summary

EAST:MK Primary Care Network has exciting opportunity for an integrated community support team (ICST) nurse to join our practice team on a full-time basis, for 37.5 hours per week over 5 days per week, between Monday and Saturday, on rotation across our 4 surgeries that make up the PCN.

You will oversee the caseload across the PCN and ensure that service delivery is implemented to the highest standard. This will include delivery of best practice, personalised care and support planning. You will provide patients with physical and psychosocial assessment, offer support and guidance to the PCN to ensure that patient needs are met through a variety of systems and continue to develop the service in accordance with the needs of the population registered with GP practices within the PCN.

We are keen to hear from experienced healthcare workers, looking to expand your contribution to healthcare and personal job satisfaction. All applicants need to be committed to improving health and putting patients first. You must be eager to undertake new ways of working and delivering healthcare, committing to under-taking the professional development required to adapt to changing circumstances.

Main duties of the job

• Provide integrated personalised care planning & an active case management system for patients of the PCN over the age of 18 years.
• Receive referrals from the 4 practices, to review patients keeping them safe and well at home.
• Identify those patients at risk of admission by visiting and assessing patients not seen in surgery for a while, to establish functional ability with an aim to assist them to engage in meaningful and purposeful daily tasks.
• Avoid or reduce hospital admissions as well as reducing long waiting times to ensure users are being treated by the best professionals for their need.
• Visit patients with recent hospital admissions/struggling at home/not known to other social services and signpost them to the most appropriate support services.
• Liaise with hospital nursing staff to prevent admission from A&E to wards.
• Work with other members of the ICST and social worker to review patients and provide a holistic and person-centred assessment working alongside social care and the voluntary sector services.
• Work with the PCN health & wellbeing coaches and social prescribers to review patients.
• Memory assessments.

About us

East:MK PCN covers a total population of approximately 55,000 patients, across its 4 practices in Milton Keynes: Ashfield Medical Centre, CMK Medical Centre, Milton Keynes Village Practice and the Grove Surgery.

Our overarching objective is to deliver the highest standard of care. We work collaboratively with colleagues in the NHS, public and community services to make as much of an impact to improving patient access and care. Patient-centred care is a firm belief in our network, and we are looking for energetic and proactive individuals that will enjoy working in a vibrant team.