About this role
Job summary
Role is for between 15 and 25 hours per week.
A Community Matron are experienced nurses with enhanced skills, that include knowledge of caring for palliative patients, physical assessment and advanced care planning to facilitate and promote independence for patients in the community through proactive case management. The Community Matrons will work closely with patients and their carers using an integrated approach alongside GPs, allied healthcare professionals, social services, hospital and voluntary services to improve the management for people who have a long term condition or a complex range of conditions
Main duties of the job
The post holder will develop the clinical case management role within the practice. The primary function of the role is to maximise the patients health, clinically assess and treat patients in a defined group and reduce risks that contribute to ill health, thereby reducing unnecessary admissions to acute services, reducing demand on GP time and facilitating the delivery of efficient, effective, co-ordinated and timely high-quality care to patients.
About us
Thornbrook Surgery is forward thinking practice with a dedicated team of clinicians and admin staff providing quality primary care services. Thornbrook Surgery is a rural three partner training practice caring for 9,500 patients. The practice is situated in the High Peak of Derbyshire, on the edge of the Peak District National Park with easy transport routes available to the surgery. We offer a busy and varied environment, negotiable hours and salary along with NHS pension and generous annual leave entitlement.
Job description Job responsibilities
Duties and Responsibilities
1. 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.
2. Undertake clinical assessment and provide treatment for patients within the defined group.
3. Link with existing services to facilitate successful discharges and to prevent re-admission to hospital.
4. Develop Partnerships and joint working within the local health and social care economy.
5. Work collaboratively across organisation boundaries to support the effective and co-ordinated provision of social care and health care services.
Clinical Requirements:
6. 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
- Making referrals for diagnostic tests
- Functional /cognitive assessment
- Assessment of social care needs.
7. 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 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.
Set up and actively participates in case review to evaluate the outcomes of care plans including social care needs.
8. 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 (ie through commissioning services for individuals)
- Understanding and working through entitlements to social care and necessary financial assessments.
9. Be aware of and adhere to, the Professional bodies Standards for administration of Medicines Act 1992, and the Misuse of Drugs Act 1971.
Further details of the Job Description please see attached document.
Person Specification
Skills and Knowledge Essential
Understanding of the principles of case management 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 workload Proficient IT skills Excellent interpersonal skills; including negotiation, influencing and presentation Risk Assessment skills Self-management and motivation skills Confidence to challenge traditional practice and persistence to address difficult issues Networking knowledge and understanding of local services Awareness of factors which contribute to good health and the importance of promoting these in line with organisational public health policy Clinical Assessment skills Working knowledge of cognitive function and its effect Moving and handling skills (including ability to assess need) Clinical decision making Venepuncture and cannulation Palliative/end of life care skills
Qualifications Essential
Relevant Clinical Professional Qualification Post registration experience Caseload Management Experience
Desirable
District Nursing Prescriber
Experience Essential
Experience of working with patients with long term conditions Experience of working with patients who are end of life 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
Desirable
Experience of initiating and implementing clinical care/protocols
Job Specific Requirements Essential
The ability to travel independently across the community The ability to work flexibly in accordance with service needs
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).
Employer details Employer name Thornbrook Surgery
Address Thornbrook Surgery
Thornbrook Road
Chapel-en-le-frith
High Peak
Derbyshire
SK23 0RH
United Kingdom
Employer's website https://www.thornbrooksurgery.co.uk/ (Opens in a new tab)