About this role
Job summary
An exciting opportunity has become available for an enthusiastic and forward-thinking Nurse Associate to join the First Coastal PCN in a new role that will be developed as it progresses. The successful candidate will be joining our Primary Care Community team, working with GP surgeries, community staff, Care Co-Ordinators, Clinical Pharmacist, Occupational Therapist, Health & Well Being Coaches and Social Prescribing Link Workers.
Main duties of the job
The Nurse Associate role is seen as a critical and evolving post to support the Enhanced Health in Care Homes (EHCH) Multi-Disciplinary Teams across the PCN footprint to deliver effective, co-ordinated care for vulnerable and frail adults, particularly those at high risk of a hospital emergency admission, ED attendances or out of hours care. The role will also support the vulnerable housebound in their own usual place of residence.
This role involves working very closely with the practices and the Multi-Disciplinary Team within the PCN. The role is pivotal in ensuring all care home patients receive the best possible care and service. The Nursing Associates role will support the GP practice colleagues and the Multi-Disciplinary Team in coordinating and performing all key activity including access to services, MDT meetings, advice and information, and ensuring health and care planning is timely, efficient, and patient-centred. The role will include supporting digital initiatives and includes responsibilities for the co-ordination of the patients journey through primary care.
The role will also work closely with Practices, PCN and Care Home teams to help create and get agreement on a long-term plan for the structure and processes to support the Multi-Disciplinary Team (MDT) meetings and the ongoing patient case management.
A full UK driving licence is needed to be able to travel to sites within the PCN area.
See attached job description for more details of the role.
About us
First Coastal PCN covers a population of approximately 84,000 patients, this is made up of seven practices, Marsico Medical Practice (Mablethorpe), Hawthorn Medical Practice (Skegness), Beacon Medical Practice (Skegness), Merton Lodge (Alford), Spilsby Surgery, Stickney Surgery and Old Leake Medical Practice. These practices work together across coastal and rural to deliver care to the local population.
Job description Job responsibilities
Main Duties
Support the Enhanced Health in Care Homes (EHCH) multi-disciplinary team (MDT) including same day visiting service and nursing service.
To work as a key member of the team to help create and get agreement on the structure and processes to support effective MDT meetings
To liaise with the registered GP and other practice-based staff in addition to all other providers and services utilising, where appropriate, a multi-disciplinary approach.
Support people to improve and maintain their mental, physical, behavioural health and well-being, promoting health and preventing ill health
To recognise changes in a patients condition/deterioration which require the intervention of others and know when to refer to the supervising Registered Nurse and other senior colleagues for reassessment of patient care.
To recognise and work within the limits of their own competence.
To ensure that high standards of nursing care are given and maintained, acting to raise concerns when standards are not being maintained following local policy and procedures.
To be involved with practice initiatives to improve patient safety and care.
To act as an advocate for the patient and family, including promoting and protecting their interests, privacy, rights, equality and inclusion.
To implement and review individual care plans, self-management plans and to agree trigger thresholds to contact the multi-disciplinary team.
Provide enhanced support to Nursing and Residential Care homes with a focus on strengthening relationships and improving access through information sharing, education and advice.
To ensure all residents of Nursing and Residential Care homes have care plans (including dementia where needed) and to provide a holistic review of all people in these homes with updates of their care plans.
Communicate any care plans to the GP and any other members of the EHCH multi-disciplinary team and stakeholders involved in the persons care and upload to the relevant records.
Act as a contact to assist with case management of patients at risk of admission, identifying sources of support in liaison with case managers.
To provide support to individuals, their families and carers to take control of their health and well-being, live independently and improve their health outcomes, as a key member of the PCN multi-disciplinary team.
To provide co-ordination and navigation with the aid of digital tools for people and their carers across health and care services.
To attend MDT meetings as appropriate.
Maintain accurate and up to date records of patient contacts using GP clinical systems and other IM & T systems relevant to the role
Support the Clinical Director and member practices in the delivery of the PCN DES specifications.
Administrative Duties
To ensure that action points identified with the MDT are recorded and followed, upping risk-profiling strategies and tools to identify at risk patients, including those patients who have multiple hospital admissions, ED attendances and unplanned out of hours care, and implement an agreed structured process on how this information will be fed into MDTs.
To work with the wider MDT to identify appropriate case managers for high risk patients to ensure that patients are reviewed and anticipatory care plans are developed.
Ensure that all patients Care Plans, Treatment Escalation Plans, DNARs and associated reviews and patient-related correspondence are available at the MDT meetings, liaising with all agencies as appropriate, access and auditing IT systems to ensure relevant information is available. The need to work closely with the PCN Care Co-Ordinators is key to this role.
To liaise with acute hospitals regularly, cross referencing admission data with the at risk list, and co-ordinating the sharing of key information between the acute hospitals teams, care/nursing homes and the clinical lead of the EHCH team.
Under the guidance of the supervising Registered Nurse, assist with the discharge process to reduce length of stay in the acute/community hospital setting.
Other responsibilities
To assist the PCN in setting and realising the PCN vision and values
To play a role in the delivery of high-quality primary health care services
Maintain a working relationship with local health and care providers to enable service delivery of mutual benefit and build a network and knowledge of referral routes to and from service providers.
To establish and maintain effective liaison with stakeholders including health, voluntary, social and education resources, attending relevant meetings as necessary.
Refer patients and/or introduce them to appropriate organisations within the PCN footprint and nationally (where appropriate), eg voluntary, statutory (local authority) and local NHS organisations.
Support the PCN Manager in providing KPI reports for submission as requested.
To be familiar with and follow PCN and practice policies and procedures as appropriate.
To have due regard for own personal safety and that of learners, patients and carers, in particular have regard to moving and handling regulations, restraining policies and ensure the safe positioning of self and others.
To decide work priorities for own work area, balancing responsibilities and changing priorities to meet deadlines, ensuring these remain in accordance with those of the service as a whole.
Support, supervise and act as a role model to nursing associate students, health care support workers and those new to care roles, reviewing the quality of care they provide, promoting reflection and providing constructive feedback.
Support service and practice development to meet the needs of the local population.
Be flexible and response to changing requirements
Be able to work using own initiative as well as being part of a team.
As this is a new and evolving role, this is not an exhaustive list of duties and responsibilities, and the post holder may be required to undertake other duties that fall within the grade of the job, in discussion with their line manager.
The content of this job description will be reviewed regularly in the light of changing service requirements as First Coastal PCN evolves and any such changes will be discussed with the post holder.
CONFIDENTIALITY
In the course of seeking treatment, patients entrust us with, or allow us to gather sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.
In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the PCN as a business organisation. All such information from any source is to be regarded as strictly confidential.
Information relating to patients, carers, colleagues, other healthcare workers or the business of the PCN may only be divulged to authorised persons in accordance with the employing practice policies and procedures relating to confidentiality and the protection of personal and sensitive data.
Person Specification
Skills and Knowledge Essential
An excellent understanding of data protection confidentiality issues. Excellent communication skills and the ability to adjust communication style and content to suit the audience. Demonstrable commitment to professional and personal development. Change-management skills and ability to support patients to change lifestyle. Negotiation and conflict management skills. Good IT Skills and ability to learn new systems. Understanding the determinants of health to include social, economic and environmental factors. Understanding of, and commitment to, equality, diversity and inclusion. Full driving license and use of car for work.
Desirable
Ability to identify determinants on health in the local area. Awareness of issues within the wider health economy. Knowledge of the needs of patients with long-term conditions. Training in motivational coaching, behavioural change and goal setting. Knowledge of organisational structures and relationships in health and social care, well-being, social prescribing and third sector.
Qualifications Essential
Registered Nurse Associate on the NMC Register Nurse Associate Foundation Degree qualification Evidence of working to the Nurse Associate Proficiency standards Evidence of continuing professional development Experience of primary/community care and working with complex patients
Experience Essential
Experience of primary/community care and working with complex patients. Experience using SystmOne clinical system. Experience of supporting patients, their families and carers in a related role.
Desirable
Experience of working directly in a community development context, adult health and social care, learning support or public health/health improvement. Experience of supporting people with their mental health. Experience of data collection and using tools to measure the impact of services. Experience of partnership/collaborative working and of building relationships across a variety of organisations including the voluntary sector.
Personal Attributes Essential
Has a planned and organised approach with an ability to prioritise their own workload to meet strict deadlines Ability to work independently without direct supervision, as well as collaboratively in a team Committed to person-centred, non-discriminatory practice. Forward thinking. Excellent interpersonal skills. Able to maintain judgement under pressure. Able to maintain motivation, drive and enthusiasm. Flexible approach to work. Ability to travel around the PCN patch to deliver patient care.
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 First Coastal PCN
Address Marisco Medical Practice
Stanley Avenue
MABLETHORPE
Lincolnshire
LN12 1DP
United Kingdom
Employer's website https://www.mariscomedicalpractice.com/ (Opens in a new tab)