Swydd-ddisgrifiad a phrif gyfrifoldebau manwl

Communications and Working Relationships

The post holder will be responsible for managing a caseload and ensure patients are discharged from the service optimised on evidence-based treatments. The post holder will be an expert practitioner providing advice and support to patients and members of the multi-disciplinary team.

Main Clinical Duties

To work as an autonomous, advanced nurse practitioner, utilising advanced clinical assessment and history taking skills in order to assess and provide individualised treatment plans for patients with confirmed Parkinsons disease.

Plan, initiate and co-ordinate ongoing assessment and monitoring of complex treatment plans aimed at improving prognosis, improving symptoms, reducing hospital admissions and facilitating discharge.

The setting up and running of a nurse led clinic in various community locations.

Ensure all referrals are triaged and allocated appointments in a local clinic based on clinical need and urgency.

Independent non-medical prescribing where appropriate, ensuring appropriate monitoring and response to all treatments prescribed. Ensuring prescribing is within national and European treatment guidelines.

Request, reviews and interpret the results of key investigations and make recommendations to the General Practitioner or prescribe the changes in medications as a result of the key investigations.

Ensure all assessments are documented and communicated to the General Practitioner and in particular if medications are prescribed or doses altered to ensure continuity of care and ensure patient safety.

Apply clinical judgement in situations where no guidelines exist. Seek guidance from Consultant colleagues when beyond own scope of professional practice.

Frequently breaking bad news regarding poor prognosis, discussing a clinical deterioration and the likelihood of pending death. Dealing independently with distressed patients and relatives, utilising advanced communication skills. Managing patient and relatives unpredictable responses to grief and bad news.

Initiate conversations around end of life planning and patient wishes regarding resuscitation for completion of a Respect Form, and advance care planning. Ensuring any decisions made with the patient are documented according to trust guidelines and communicated to the multidisciplinary team.

Deliver evidence-based compassionate care which places the patient at the heart of practice. Care will be responsive to individual needs and reflect current national guidelines.

Make direct referrals to other teams and specialists as required ensuring optimal care for the patient.

Professional/Clinical Responsibilities

To carry out comprehensive assessment at an advanced level utilising critical analysis to inform clinical judgement and develop care plans that optimise treatment and client-centred outcomes.

This will include history taking, systematic physical examination, and the collection of baseline data and the identification of risk to develop an individualised treatment plan.

Analyse signs and symptoms, laboratory tests and other measures of function, in formulating a diagnosis.

Independent nurse prescribing skills with medicines management used in collaboration with appropriate members of the multi-disciplinary team to plan and implement treatment for changes in the health status of the patient.

Management plans will involve the patient in the decision making process based on needs, preferences and choices with the resource available to include preventative and anticipatory care. End of life care planning to include family and significant others.

Make direct referrals and order investigations as necessary following agreed protocols and pathways of care, ensuring documentation adheres to Trust and NMC guidelines. Ensuring that all member of the multidisciplinary team involved in the care have been updated.

Identify patients who will benefit from joint case-management to promote joint working with place based teams, community and primary care colleagues to optimise outcomes.

Arrange and facilitate regular MDT meetings to ensure collaborative communication and planning to meet the needs of the individual.

Be accessible to colleagues/providers for communication across a range of health and social care settings to enhance patient experience.

Ensure a robust process is in place to review care/treatment plans and undertake regular medication reviews.

Working collaboratively with GPs and practice nurses to provide support and advice, run clinics in the community setting and support with the annual review of patients the caseload

Monitor indicators of Parkinson’s disease, anticipating possible decline and proactively manage this to enhance wellbeing, maintain independence and prevent inappropriate hospital admissions.

Build relationships across professional and organisational boundaries, anticipating boundaries whist working towards ways to improve communication.

To provide learning opportunities for students/colleagues and other health care professionals.

To provide case management support and guidance for all clinical practitioner colleagues across Warwickshire on an ad hoc and at least a bimonthly basis face to face, or by other means of communication such as Microsoft Teams.

To work jointly with Clinical Service Lead to deliver the shared objectives of the integrated service

Ensure that all record keeping complies with NMC Guidelines and Trust policy.

To undertake clinical supervision, professional development and undertake annual PDR