Digital Health Nurse

Job responsibilities

The post holder will:

1. Be able to combine high level remote monitoring with telephone assessment for patients with short and long-term conditions. Intervene when markers for deterioration are evident. Subsequently, initiating medical and/or nursing/therapy treatments, by alerting and referring to primary care multidisciplinary teams and professionals. These actions will ensure that interventions for patients on the caseload are delivered in the community setting and prevent unnecessary hospital admission.

2. Work with partners in nursing and residential care to ensure optimum health outcomes for their residents.

3. Develop shared caseloads with Integrated Care System (ICS) Network by acting as an integral member of the community team, working with a shared vision, and developing caseloads in partnership with Integrated Care System partners.

4. Possess well developed clinical and professional leadership ability and use this proactively for the benefit of the Digital Health team. Support the Digital Health Team Leader in their management role when required. Leadership skills will also be utilised to support the wider community includingPrimary Care, Social Care, and all other provider organisations to deliver high standards of care to patients.

5. Supervise other health and social care professionals in the delivery of health promotion activities via the Digital health model, e.g. chronic disease management self-help signposting.

6. Work in alignment with Primary Care, for established practice populations, toward a shared vision of seamless management for patients with short- and long-term conditions within the Primary Care and the Community setting.

7. Work with ICS partners in Primary and Social Care to further develop the Digital Health model for cohorts of patients managed within local populations.

8. Maintain accountability for practice following the Nursing and Midwifery Council Code of Professional Conduct or the Health Care Professions Council and compliance with EBPC Policies and Procedures.

9. Maintain legible, accurate and up to date records that are dated and signed in accordance with EBPC Policies and the Nursing and Midwifery Council / Health and Care Professions Council standards on record keeping.

10. Work autonomously with patients, their families and carers managing referrals according to need and priority.

11. Negotiate and agree with the patient, carers and other care professionals, individual roles, and responsibilities with actions to be taken and outcomes to be achieved, referring on to other services or professionals as appropriate.

12. Critically analyse complex clinical data and information to inform diagnosis. Where appropriate, refer within Primary Care to improve health outcomes for patients on the Remote Monitoring caseload.

13. Understand and support the achievement of EBPCs business plan objectives and performance targets; participating, in screening and needs assessment as required.

14. Identify the potential for service developments, risks and deficits and inform as appropriate to the Remote Monitor Service Manager making recommendations based on specialist knowledge.

15. Be wholly accountable for practice taking every reasonable opportunity to sustain and improve knowledge and professional competence and, ensure that all aspects of professional behaviour as required within the NMC or HCPC Codes of Professional Conduct are followed at all times.

16. Assist the Team Leader to manage the effective use of resources within the Remote Monitoring team and participate in regular review meetings with the Team Leader/Nurse Lead.

17. Develop and sustain an effective and positive working relationship with a wide range of multidisciplinary teams and individual professionals including Specialist Nursing Services, Community Nursing services, Therapy services, GPs, Practice Nurses and Primary Care staff.

18. Have experience of Luscii patient management platform or similar.

19. Have experience with other clinical patient management systems: Adastra, EMIS, Connected Care.

PATIENTS CARE The post holder will:

1. Use advanced clinical skills to remotely monitor and assess the physical and psychosocial needs of a defined client group.

2. Use advanced generalist clinical skills to identify subtle changing health care needs of patients. Subsequently, being able to competently discuss treatment options with other generalists and specialists.

3. Demonstrate responsibility and accountability for the Digital Health clinical caseload and escalate care needs across the whole patient pathway when this is required. This includes ensuring a robust relationship and constant interface with Primary Care and Community Multidisciplinary teams.

4. Review individualised care plans for patients with short- and long-term conditions on admission to Remote Monitoring, so that their condition remains as stable as possible and, where appropriate, hospital admission is prevented.

5. Work with partners in nursing and residential care to improve the health outcomes of the residents and so prevent unnecessary hospital admissions or extended in-patient care episodes.

6. Analyse complex patient situations establishing a therapeutic relationship to assist the individual patient to adjust to their illness and care with the Digital health service.

7. Use assessment tools/skills that will ensure an appropriate level of nursing or therapeutic intervention so that patients who present with complex needs are referred/escalated via the appropriate care pathway.

8. Discuss all treatment options with sensitivity, knowledge, and expertise. and to act as patient advocate and maintain patient confidentiality.

9. Deliver care that is patient centred, respecting diverse cultural backgrounds, and requirements.

10. Work in partnership with the patients to empower them to make informed choices about their healthcare and support choices.

11. Offer a supportive service to patients and their carers from diagnosis through all stages of the disease process, in conjunction with other healthcare professionals using a range of communication skills to manage care and information empathetically.

RESPONSIBILITIES FOR PEOPLE AND TRAINING

1. Provide patients, families and carers with tailored advice and support to increase understanding of signs and potential causes for acute exacerbation of underlying conditions. This may aid patient, family and carers engagement with lifestyle changes that would be advantageous to health.

2. Be responsible for providing and maintaining a learning environment and maximise opportunities for education and development in the clinical area to enhance individual development and performance in the delivery of high standards of care.

3. Act as expert resource and assist in teaching advanced clinical skills for other health care professionals in the Digital Health environment. Take part in the process of clinical supervision and participate in clinical supervision and mentorship of others.

4. Take responsibility for your own personal and professional development; maintain competence, knowledge, and skills commensurate with role.

5. To be actively involved in clinical staff recruitment in the Digital Health Team when required by EBPC.

OTHER FACTORS

1. Maintain personal knowledge, skills, and competency through appropriate CPD, training and development opportunities.

2. Keep up to date with new developments and legislation.

3. Using IM&T support systems.

4. It may be necessary to change the days worked as the service develops and grows; therefore, flexibility is essential.

5. You will be dealing with complex problems and circumstances with patients and their families which will at times be challenging.

GENERAL

This post is one of continual development. The job description is intended as a guide to the principal duties and responsibilities of the post and complements individual objectives set in line with EBPC annual business objectives. Responsibilities will be reviewed periodically in line with service priorities and duties may change or new duties be introduced after consultation with the post holder.

CRIMINAL RECORDS BUREAU DISCLOSURE

This post may require you to hold a current CRB Certificate which EBPC make application for every three years. Under the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1075, applicants for this post are among those who are not entitled to withhold information about any previous criminal conviction.

FLEXIBILITY

The EBPC is currently working in a climate of great change within the healthcare sector. It is therefore expected that all staff will develop flexible working practices within EBPC and across the health network and at other organisation levels as appropriate, to be able to meet the challenges and opportunities of working within the new healthcare environment.

MOBILITY

The post holder will be expected to work at any establishment at any time throughout the duration of their contract, within the location of EBPC as agreed with the post holder.

HEALTH AND SAFETY

EBPC attach the greatest importance to the health and safety of its employees. You are expected to make yourself aware of and comply with EBPCs and local Health and Safety policies, a copy of which is retained by your manager.

CLINICAL GOVERNANCE

EBPC aim to provide the highest standards of care. To further this aim you are expected to adhere to acceptable working practice as defined in EBPC policies and guidelines. You also have a personal responsibility and accountability to your team and service to keep yourself up to date and, if you encounter unacceptable practice, to raise it or deal with it through accepted channels.

Qualifications

Essential

• Registered nurse or AHP
• Further clinical education to Masters level (level 7) in relevant discipline or equivalent training and experience or working towards
• Remote triage assessment

Desirable

• Further qualifications relevant to community nursing
• Frailty, long term conditions or additional Module attained at level 7
• Awareness of recent Government initiatives that may affect future clinical practice
• To be knowledgeable of the clinical governance agenda and have an awareness of commissioning
• Post graduate community qualification e.g. community specialist practitioner
• Teaching qualification
• Experience with Adastra, EMIS and Connected Care systems

Knowledge and Skills

Essential

• To be able to communicate with people from a wide range of backgrounds
• To be able to work flexibly and sensitively
• Wide range of interpersonal and communication skills
• Competence in a wide range of nursing skills
• IT literate
• Undertake specific nursing tasks requiring precision and/or intense concentration. Undertaking complex nursing skills
• Ability to sensitively inform service users on complex and distressing issues. Able to support and facilitate staff in dealing with these situations
• To be flexible and adaptable

Desirable

• Report writing
• Further training in dealing with difficult situations.
• Specific speciality area
• Teaching experience

Experience

Essential

• Significant experience of working with a multi-disciplinary team
• Leadership experience
• Setting and monitoring standards of care
• Experience within a wide range of patient/client care groups
• Community services experience

Desirable

• Profiling community needs and targeting identified health needs of population
• Evidence of innovative and flexible approach to care and the organisation of care
• Teaching experience

Other Job-Related Requirements

Essential

• Willing to work in other areas of the EBPC as and when required to do so
• Driven to achieve
• Self-motivated
• Good time management

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).