About this role
Job summary
We are seeking an experienced, motivated, and compassionate clinical practitioner to join our Care Management Service. This is an exciting opportunity for a highly skilled professional to lead the provision of proactive, person-centred care for adults with complex health needs, multiple long-term conditions, frailty, and those at risk of hospital admission. We have two posts; Ipswich East and Ipswich West Integrated Neighbourhood Teams.
You will provide advanced clinical assessment, case management, and care coordination, working closely with patients, carers, primary care colleagues, community teams, social care, and voluntary sector partners. You will play a pivotal role in identifying individuals at greatest risk, supporting self-management, reducing health inequalities, preventing avoidable admissions, and enabling patients to remain safely and independently within their own homes.
You will demonstrate strong clinical leadership, excellent communication skills, and a commitment to delivering high-quality, holistic care. You will be passionate about integrated working and ensuring seamless care across organisational boundaries, while supporting service improvement and positive outcomes for patients and their families.
This role offers an excellent opportunity to make a meaningful difference within the community by supporting individuals with complex needs through effective care planning, risk management, and collaboration across the wider health and social care system
Main duties of the job
The CMS Clinical Practitioner is an experienced autonomous practitioner working within the Care Management Service, delivering proactive, personalised and coordinated care for individuals identified as being at high risk of unplanned hospital admission, emergency department attendance and escalating health and social care needs. The role supports the objectives of the Care Management Service through prevention, early intervention, care coordination and multidisciplinary working.
You will work within a multidisciplinary and multi-agency model, supporting individuals with frailty, multimorbidity, complex physical health conditions, mental health needs, functional impairment and social complexity. Using enhanced assessment, clinical reasoning and care management skills, the practitioner will undertake holistic assessments, develop personalised care plans, facilitate rapid intervention and support admission avoidance and timely discharge.
You will contribute to the CMS multidisciplinary team (MDT) process, participate in desktop triage, support proactive monitoring of patients, respond to deterioration identified through clinical review or Data Initiated Follow-Up (DIFU) processes and facilitate progression through active care management, step-down and discharge pathways.
The role may be undertaken by a registered nurse, paramedic, occupational therapist, physiotherapist or other appropriately qualified healthcare professional working within their professional scope of practice.
About us
We are ESNEFT and we provide hospital and community health services to almost one million people across east Suffolk and north Essex. Our dedicated staff deliver care from acute hospitals in Colchester and Ipswich, community hospitals, surgeries, community clinics and in patients' own homes.
We are one of the largest NHS organisations in England, employing more than 12,000 staff.
We pride ourselves on supporting our staff. We offer a wide range of training and development opportunities, as well as flexible working options.
Along with supporting you to achieve your career goals we offer a generous pension scheme, unsocial hours payments (where applicable), 27 days annual leave on commencement (pro rata) and access to a range of NHS discounts. Our Staff Health and Wellbeing programme offer a variety of services.
Our philosophy is that Time Matters to everyone. Across the Trust, we concentrate on improving the things we do and removing those which cause time delays for our staff and patients.
We are investing in our commitment to Time Matters with a partnership with leading electronic patient record (EPR) supplier Epic. This digital transformation will bring what's widely regarded as the world's best EPR system to ESNEFT, transforming life in hospital for staff and patients.
If you are passionate about patient care and want to develop your skills and knowledge, then we want to hear from you.
Find out about living and working here - www.youtube.com/watch?v=GkPu7HphU8A
Job description Job responsibilities
For full details of the responsibilities and duties of this role please see the attached job description.
Person Specification
Experience Essential
oSignificant post-registration clinical experience. oExperience of autonomous clinical practice. oExperience managing patients with complex needs oExperience of multidisciplinary team working. oExperience of community, acute medicine, primary care, urgent care, rehabilitation, frailty or integrated care services. oExperience of risk assessment and management. oExperience of care planning and care coordination
Desirable
oExperience of case management services. oExperience of working with high-intensity users of health services. oExperience of admission avoidance services. oExperience of service development or quality improvement projects
Qualifications Essential
NMC/HCPC or other appropriate UK healthcare professional regulator oDegree or equivalent professional qualification. oEvidence of ongoing professional development. oIndependent Prescribing qualification. oTeaching and mentoring qualification
Desirable
oMaster's level study or equivalent experience. oAdvanced Clinical Assessment qualification. oLeadership or management qualification
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 East Suffolk and North Essex NHS Foundation Trust
Address Constantine House
Ipswich
IP1 2DH
United Kingdom
Employer's website https://www.esneft.nhs.uk/ (Opens in a new tab)