Job responsibilities
This
role will provide support to patients in the community with long term
conditions such as diabetes, chronic
respiratory disease, chronic pain etc. and will require some clinical activity
through supporting practices with the vaccination programme for house bound
patients, working as part of the practices extended team.
Establish treatment and care plans that
anticipate clinical changes, deterioration or escalation of need. Plans may
include decisions around end of life; preferred place of care, preferred place
of death and cardio-pulmonary resuscitation.
Make clinical decisions for patients on the
caseload with GP support.
Promote the understanding and use of
standardised monitoring and predictive tools, investigations and techniques.
Support carers and develop personalised
approaches to care. Work with patients on self-management strategies. Support
carers and patients to have confidence and competence to self-test and monitor
and be proactive on known triggers to ill-health.
Promote the appropriate use of prescribed and
over the counter medications, homely remedies, wound care and nutritional
products. Take appropriate urgent action where the risk of harm is identified
and initiate alerts to appropriate agencies where non-clinical risk is
suspected or identified. Liaise with pharmacists/specialist community elderly
care pharmacist on the appropriate documentation, information, packaging and
labelling of medication to support self-management and reduce risk.
Liaise and provide support on the management of
patients across primary, secondary and tertiary care services. Identify
strategies to avoid unnecessary, multiple or missed attendance at hospital
appointments. Signpost patients to access appropriate dental, optical and nail
cutting services.
Leadership
Supporting the primary care network teams,
having a flexible approach to managing the day to day priorities of their
workload and support the objectives of the team as a whole.
Performance and attitude to reflect the
principles of the professional code of conduct and be commensurate to the role
as a clinical practitioner.
Support the development and review of policies
for the clinical team, procedures, supporting with audits and strategies to
ensure progress in the delivery and outcomes of the project.
Develop communication links and maintain good
working relationships within the primary care network team and external
agencies.
Advocate for patients in situations where
concerns about care or professional conflict arise. Use appropriate avenues of
reporting and escalate concerns in a timely fashion. Adhere to safeguarding
policies.
Education and Development
To develop and maintain own clinical practice,
identify clinical supervision needs and participate in mandatory training and
appraisals.
Support the educational, training and
professional development of colleagues.
To advise the clinical team and organisation on
learning needs that arise through clinical practice, outcomes of audits,
contacts within the project.
To maintain a willingness to explore and
undertake new and different ways of working that offer improvements to
practice, service delivery or clinical outcomes for patients.
Participate in link and educational events with
other organisations aiming to promote same or similar outcomes.
Positively promote the aims of the project to
other professional organisations, to patients and the public.
Information Governance
Maintain accurate and appropriate recording of
confidential and sensitive information.
Ensure consistency of information held across
different media.
Maintain the security and integrity of
information held electronically or in paper format.
Ensure written or verbal consent is sought where
information needs to be shared outside of agreed networks.
Ensure clinical investigations, results, their
interpretation and treatment options are discussed and documented appropriately
within the team and with appropriate external agencies.
Confirm and support the role of all patient
designated legal health advocates.
Communicate the rationale for determining the
level of urgency of interventions and where necessary, initiate onward referral
to appropriate agencies.
Service Development
Identify processes that identify prevention of
hospital admissions/ other savings for future project funding
Identify developing themes and trends that sit
outside of the current project and may require consideration for inclusion in
later service level agreements.
Identify and advise on reduced or redundant
activity to be reviewed or excluded in later planning arrangements.
Identify risks to the project arising from
unknown or unforeseen situations in the locality or within the client group.
Identify equipment, skills or further learning
to support the future success of the project.
