Job summary
Are you a Registered Nurse with an interest in caring for people living
with long term conditions and increasing frailty, to support them to remain
living independently at home or a residential care setting, ensuring planned,
optimised and co-ordinated health care for them and their families.
Poole Central Primary Care Network, provides services on behalf of five
GP Practices to the population of central Poole town, Hamworthy, Upton and Lytchett.
We are looking to recruit a registered Nurse to our Enhanced Care Team,
ideally with previous experience in a community or primary care setting who
would like to join our multi-professional Enhanced Care Team, providing both on
the day urgent support and proactive planned care and long-term conditions
management.
As an
experienced RGN, the role will be to co-ordinate
the clinical case management for frail and complex health patients, who are at
risk of further deterioration in health, an avoidable hospital admission or
unnecessary length of hospital stay.
This role is offered on a part-time/full-time basis and open to a flexible working pattern.
You can find out more about the PCN on our website:
www.poolecentralpcn.nhs.uk
Main duties of the job
To work as a member of the Poole Central
Primary Care Network Enhanced Care Team to co-ordinate clinical case management
for frail and complex patients and those with long term conditions who are at
risk of further deterioration in health or an avoidable hospital admission or
unnecessary length of hospital stay.
To be responsible for a case-load of patients
who have either been identified using an agreed case finding tool (Electronic
Frailty Index or Rockwood) or whom have been identified by another healthcare
professional as frail or as having a long-term condition.
As part of a team approach, to be responsible
for identifying an individuals principle needs through a holistic,
comprehensive assessment, develop care plans and work closely with other
members of the MDT and primary care/community care team to support patients in
the community.
To support preventative
care, screening and patient education to enable the patient to manage frailty
and long-term condition.
To be adaptable and able to work across all
aspects of the service, including where needed, supporting the Care Home and
Acute home visiting services.
About us
Poole
Central PCN is the second largest PCN in Dorset and one of the first to develop
an operational Hub with a central co-ordination team and clinical teams
co-located in a dedicated building.
The PCN
services comprise a multi-professional Enhanced Care Team, responding to the
needs of the population who are housebound or living in long term residential
care. The ECT comprises ANPs, RNs, HCAs, Paramedics, Specialist Diabetes and
Respiratory Nurses and Clinical Pharmacists, working together to optimise clinical
outcomes and support people to remain living independently whenever possible
and working closely with Practice Teams to ensure effective co-ordinated care.
We work
collaboratively with partners in health and social care and are currently
developing a number of pathways that involve models if integrated working and
information systems and digital technology have a key part to play in achieving
greater efficiency in how we work.
The
post-holder will be employed through The Adam Practice (Lead Practice) on
behalf of the PCN and details of Terms and Conditions of employment are
available on request.
Job description
Job responsibilities
To undertake a holistic full
assessment of the physical and psycho-social care needs of complex and frail
patients and those with long term conditions, involving carers and relatives.
To establish an individuals functional capabilities with regards to
frailty, as well as ability to manage other long-term health conditions.
To provide cognitive assessment
and identification of mental health needs, referring as appropriate.
To identify an individuals principle needs and support them in the
development of plans to address related issues, supporting self-management
where feasible.
To develop a person centred,
evidence-based holistic health and social care plan in conjunction with
medical/other health professionals and social care colleagues.
To provide co-ordination of clinical case management for complex and
frail patients and those with long term conditions, who are at risk of
declining clinical quality of life or avoidable hospital admission.
To discuss assessment outcomes with patients, carers, their GPs and
other health and social care professionals.
To liaise closely with other health and social care professionals to
provide community care and support to meet the needs of an individual.
To identify social isolation and
loneliness, being proactive in sign-posting to relevant resources to empower
patients to remain active and engaged within their communities. Work closely
with the social prescribing team.
Using a high level of communication and interpersonal skills,
establish effective working relationships with patients, their families and
carers.
To recognise and identify a
deterioration in an individuals health and act promptly to reduce risk of
rapid deterioration or where appropriate avoid hospital admission. Refer onto
relevant health professional as required.
To educate individuals and
carers/relatives to identify early warnings of deterioration in order to
facilitate rapid management of complication or crises.
To facilitate early discharge, where
possible, from hospital for case managed patients by co-ordination of care and
services to be delivered within primary care/community.
To identify those individuals with more complex health needs and
refer for an holistic, multi-dimensional, interdisciplinary assessment with
members of the MDT specialising in older peoples health and/or specialising in
long term conditions, to include appropriate specialist secondary care
expertise.
To participate in the MDT
meetings, where appropriate identify patients that may require an MDT review.
Job description
Job responsibilities
To undertake a holistic full
assessment of the physical and psycho-social care needs of complex and frail
patients and those with long term conditions, involving carers and relatives.
To establish an individuals functional capabilities with regards to
frailty, as well as ability to manage other long-term health conditions.
To provide cognitive assessment
and identification of mental health needs, referring as appropriate.
To identify an individuals principle needs and support them in the
development of plans to address related issues, supporting self-management
where feasible.
To develop a person centred,
evidence-based holistic health and social care plan in conjunction with
medical/other health professionals and social care colleagues.
To provide co-ordination of clinical case management for complex and
frail patients and those with long term conditions, who are at risk of
declining clinical quality of life or avoidable hospital admission.
To discuss assessment outcomes with patients, carers, their GPs and
other health and social care professionals.
To liaise closely with other health and social care professionals to
provide community care and support to meet the needs of an individual.
To identify social isolation and
loneliness, being proactive in sign-posting to relevant resources to empower
patients to remain active and engaged within their communities. Work closely
with the social prescribing team.
Using a high level of communication and interpersonal skills,
establish effective working relationships with patients, their families and
carers.
To recognise and identify a
deterioration in an individuals health and act promptly to reduce risk of
rapid deterioration or where appropriate avoid hospital admission. Refer onto
relevant health professional as required.
To educate individuals and
carers/relatives to identify early warnings of deterioration in order to
facilitate rapid management of complication or crises.
To facilitate early discharge, where
possible, from hospital for case managed patients by co-ordination of care and
services to be delivered within primary care/community.
To identify those individuals with more complex health needs and
refer for an holistic, multi-dimensional, interdisciplinary assessment with
members of the MDT specialising in older peoples health and/or specialising in
long term conditions, to include appropriate specialist secondary care
expertise.
To participate in the MDT
meetings, where appropriate identify patients that may require an MDT review.
Person Specification
Qualifications
Essential
Desirable
- Mentorship Qualification
- Post Graduate qualification
Experience
Essential
- Previous experience working in primary/community care setting or working in a relevant secondary care role ie. Care of the Elderly
- Experience of working under own direction
- Ability to self-motivate, organise and prioritise workload
Desirable
- Experience of supporting service improvement
- Experience at supporting peers, new learners and mentoring junior colleagues
Personal Qualities and Attributes
Essential
- Excellent written skills and a high level of verbal communication skills
- Demonstrates compassion and understanding of holistic, patient centred care
- Ability to use own initiative and recognises own scope limitations
- Demonstrates team player qualities
Information Technology
Essential
- Evidence of working with IT systems including Word, Access, Excel
- Ability to handle sensitive information confidentially, full awareness of data security
Other
Essential
- Subject to the provisions of the Equality Act, able to travel using own vehicle on Network business
Person Specification
Qualifications
Essential
Desirable
- Mentorship Qualification
- Post Graduate qualification
Experience
Essential
- Previous experience working in primary/community care setting or working in a relevant secondary care role ie. Care of the Elderly
- Experience of working under own direction
- Ability to self-motivate, organise and prioritise workload
Desirable
- Experience of supporting service improvement
- Experience at supporting peers, new learners and mentoring junior colleagues
Personal Qualities and Attributes
Essential
- Excellent written skills and a high level of verbal communication skills
- Demonstrates compassion and understanding of holistic, patient centred care
- Ability to use own initiative and recognises own scope limitations
- Demonstrates team player qualities
Information Technology
Essential
- Evidence of working with IT systems including Word, Access, Excel
- Ability to handle sensitive information confidentially, full awareness of data security
Other
Essential
- Subject to the provisions of the Equality Act, able to travel using own vehicle on Network business
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).
Additional information
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).
