HealthJobsUK

Detailed job description and main responsibilities

Leadership/Managerial

1. To act as the key point of contact within the ICN proactive care pathway. The Community Matron will carry out an initial holistic assessment for all patients identified for the pathway and will then discuss the care plan generated at a MDT discussion.

2. To be responsible for the management of a caseload and maximise efficiency and effectiveness in the role to secure the best service to patients. This will include the analysis and management of complex changing clinical situations.

3. Act as a change agent and innovator, planning, implementing and evaluating change to facilitate high quality health outcomes, pioneering new services where gaps exist.

4. To provide expert advice on Long Term Conditions and suggest strategies to improve and develop services across organisational and professional boundaries.

5. To provide expert advice on frailty and ceilings of care, liaising with a local geriatrician as needed to move the patient through appropriate care pathways/into end of life pathways, when appropriate.

JOB SUMMARY

The Community Matron will work as a key member of the Integrated Care Networks Proactive Care Pathway. The proactive Care Pathway aims to successfully manage frail and elderly patients in the community through a multi-disciplinary approach to care and through the application of case management. 

The Community Matron will work closely with Primary Care to identify patients through risk stratification and develop proactive patient centred care plans, actively implementing and following through on the care plan to establish and monitor its implementation. The Community Matron role is a key role in the Proactive Management and Integration of Services for the Elderly.

 The Community Matron will proactively holistically assess and case manage a caseload of patients with highly complex needs, working closely with GP practices to identify patients that would benefit from preventative interventions in the community using clinical judgement and a risk stratification tool. The role will complement the generic district nursing and specialist roles in chronic disease management across primary and community services.

 The Community Matron will provide clinical care and clinical leadership, co-ordinating the care and case management of risk stratified patients within the Integrated Community Teams preventing unnecessary admissions and facilitating appropriate ones.

 The Community Matron will have/will be expected to develop high level skills in physical assessment and diagnostic reasoning including prescribing within their scope of practice.

 The Community Matron will work collaboratively across health, social care services and the voluntary sector to identify vulnerable older people with complex needs.

MAIN DUTIES AND RESPONSIBILITIES

6. To support in the development of the Integrated Community Teams including up-skilling colleagues (including colleagues outside of nursing) by mentoring, feedback and teaching.

7. To assist in the development of policies, procedures and guidelines to support the case management process.

8. To participate in the evaluation of the service and service development including relevant audits and research, providing reports as and when required.

9. To ensure that all necessary records are maintained in line with Bromley Healthcare and NMC requirements.

10. To have an awareness of budget management and be responsible for the efficient and effective use of resources within own practice e.g. equipment supplies and time management.

11. To act at all times as a positive role model and an advocate both for individuals and the service, networking with a variety of forums as appropriate.

Clinical

1. Be responsible for an identified caseload of patients, taking referrals from relevant health professionals in line with the current Bromley Healthcare guidelines.

2. To use advanced clinical practice skills and expert knowledge, using nationally recognised assessment tools. Undertake in depth holistic clinical assessments, including a full physical examination and identifying patient’s medical, social, psychological and spiritual needs.

3. To negotiate and develop a personal care plan with the patient, health/social care professionals, carers and/or relatives. To ensure these care plans are patient centred and that the patient signs up to the care plan and feels fully involved in its development.

4. To diagnose, instigate and review therapeutic treatments based on best available evidence to manage and improve health outcomes.

5. To provide expert clinical care and health promotion interventions.

6. To regularly monitor and review the patient’s condition to identify subtle changes in that condition, proactively manage these to enhance wellbeing and promote independence and teach relatives and carers to recognise these changes.

7. To manage individuals with chronic disease through an advanced level of autonomous practice including taking managed risks.

8. To use appropriate benchmarks to drive standards of performance in management of longterm conditions, aligning to the GP ‘QoF’ and other national frameworks as appropriate.

9. To develop therapeutic relationships with patients and carers, enabling and supporting them to be active partners in the care planning process for their current and future needs.

10. To develop and use expert knowledge and skills to order diagnostics e.g. blood tests and interpret and act on results, using clinical guidelines and policies to support clinical decision making.

11. To work in partnership with GP’s, nurse practitioners, relevant hospital consultants and others to determine a diagnosis when required.

12. To take responsibility to formulate a plan of care and follow-up, ensuring the multidisciplinary team within the ICN is fullyinvolved.

13. To work collaboratively when patients are admitted to any in-patient facility, and provide base line health data for the receiving team to support integrated and consistent care and facilitate discharge or end of lifecare.

14. To refer appropriately and in a timely way to other services and health/social care professionals.

15. Working closely with the CPNs in the community teams including supporting shared care management of long-term mental health conditions such as dementia and depression

16. To manage high risk patients pro-actively and minimise the risk of hospital admission ensuring they are in the most appropriate care environment.

17. To co-ordinate and evaluate additional support as needed, such as homecare, intermediate care, palliative care teams or geriatricians.

18. Provide advice to patients and their carers on medicines and their management

19. To prescribe as an independent prescriber, or a supplementary prescriber using a clinical management plan in accordance with DoH and Bromley Healthcare guidelines on non-medical prescribing.

20. To undertake medication reviews and to prescribe within competencies to ensure that patients are on optimal disease specific medications as per NICE and Local Guidelines.

21. Supporting the implementation of the dementia screening programme across the community teams, and supporting patients with dementia

Education and Training

1. Develop own knowledge and skills within the national case management competency framework in order to function as an advanced clinical practitioner.

2. Take an active part in the organisations review process identifying own learning and developmental needs against the Knowledge and Skills Framework (KSF) outline for the post and produce a Personal Development Plan (PDP) to meet those needs.

3. Take an active part in the organisation's clinical supervision process.

4. To act as a mentor to other staff where appropriate, providing education, training and support.

The post holder has a responsibility to safeguard children, young people and adults at risk and will be trained to the appropriate level as determined by the post.