Job responsibilities
Job Title: Acute
Frail Elderly Outreach Matron
Band: 8a
Reports
to: Practice Manager
Accountable to: Practice Manager and GP
Partners
Main Duties
To
work as an autonomous clinical practitioner to provide expert clinical care for
frail, elderly & housebound patients with acute/intensive & complex medical
needs. To diagnose, review and treat
patients in their own home.
Clinical Practice
To provide expert clinical care for
frail patients who may have multiple long term conditions and are at risk of
deteriorating health that may result in declining clinical quality of life or
avoidable hospital admission or unnecessary length of hospital stay.
Supporting and working with carers and
wider family members.
Develop relationships with staff
within the Practice, ICT, Rapid Response and Social Care relating to them on a
day-to-day basis.
Undertake comprehensive assessment of
the physical and psycho-social care needs of frail patients who may also have
complex chronic disease.
Establish an individuals functional
capabilities with regard to frailty as well as any long term conditions
clinical management.
Develop a person led evidence based
holistic health and social care plan in conjunction with medical and other
health and social care colleagues.
Develop person led care plans in
partnership with patients and their relatives.
Use a high level of communication and
interpersonal skills to communicate effectively with patients and carers, in
particular the skills needed for cognitive assessment and mental health status.
Refer individuals to mental health
and/or other services where appropriate.
Work with patients and carers to teach
and educate them about the early warning signs in order to facilitate rapid
management of complications or crises.
Enable patients to be as independent
as possible by facilitating a range of self-management strategies through
undertaking desired occupations and non-occupational activities including the
support that is available from the voluntary sector.
End of life care and support. Prescribing medication for terminal patient care
and liaising with specialist teams.
Constantly strive to identify training
needs for self and others.
To fulfil the requirements for
maintaining a professional registration.
Communication
Deliver sensitive communication to
patients and colleagues alike including carers.
Maintain effective communication within
the practice nursing team, with the nurse manager, the GPs and the whole
practice team
Clinical Practice and Quality
Work within own confidence and
professional code of conduct as regulated by the NMC.
Always produce accurate,
contemporaneous and complete record keeping of patient consultations
Support and participate in lifelong
learning and shared learning across the practice.
Understand and apply appropriate
support to the identification of vulnerable adults and children and keep up to
date with statutory child protection training, practice procedures and
protocol.
Work as an effective and responsible
member of the practice nursing team, the emergency team and the overall
practice team.
Work effectively with others following
the practice values, policies and protocols incorporating respect for all
patients and colleagues.
Manage and assess risk in a
professional manner ensuring that appropriate measures are in place to protect
staff and patients (where this is discovered not to be the case to draw this to
the attention of the nurse manager/general manager as soon as practicable).
Follow infection control guidelines
within the practice.
Follow the practice policies on
equality and diversity to ensure the absence of discrimination.
Other
Any other appropriate duties that are
requested by the Partners or Practice Manager
Will be required to work across both
The Southgates and The Woottons Surgeries
At times may be required to work
extended hours