Job summary
This role is offered on a fixed term/secondment basis for 12 months. Internal applicants who wish to be considered for a secondment opportunity should discuss with their line manager the suitability of a possible secondment.
The Complex Care at Home Matron/Clinical Case Manager assumes the role of an autonomous Clinical Practitioner, responsible for overseeing the care of their assigned patients. This entails triaging, planning, managing, and coordinating intricate care and treatment requirements within the confines of patients' homes.
As a member of the Complex Care at Home Multidisciplinary Team, they proactively manage patients with long-term conditions and at risk of deterioration, including those with frailty. The Community Matron/Clinical Case Manager provides comprehensive and specialised support to patients, carers, and families, enabling them to lead fulfilling lives alongside their conditions. They employ motivational interviewing and health coaching to establish therapeutic relationships, thereby mitigating unplanned hospital admissions. This proactive strategy fosters improved health outcomes.
The Community Matron/Clinical Case Manager works closely with primary and secondary care services, including Physical and Mental Health, as well as statutory and non-statutory agencies. This collaborative approach enables the development of personalised care plans, consistently advocating for the 'What matters to you?' principle.
Main duties of the job
- Triage: Ensure patients meet the criteria for the service.
- Holistic Assessment: Within a patient's home environment, conduct a comprehensive assessment.
- Risk Assessment: Evaluates patients' safety needs to determine the most appropriate care setting. This involves providing specialist advice and, if necessary, signposting or referring to other healthcare providers.
- Medication Assessment and Review: Assess and review medication for therapeutic effectiveness, prescribing, and/or de-prescribing in accordance with evidence-based practice, national and local protocols, and within the scope of practice and legislative framework.
- Collaborate with other prescribers (GPs, pharmacists, consultants, and specialists) to ensure continuity and safe prescribing practices.
- Case Management: Identify, prioritise, and implement case management plans to achieve health gains and maximise patient independence.
- Maintain effective and timely communication with patients, carers, and all relevant services and agencies (statutory and non-statutory).
- MDT Meetings: Attend, participate, and lead where appropriate weekly internal MDT meetings and external meetings as required.
- Provide clinical supervision to Health 7 Wellbeing Coordinator and as a line manager, have the responsibility of signing off expenses and annual leave according to Trust policy.
The qualification, training & experience requirements for the role are underlined in the Job Description/Person Specification.
About us
We have a skilled and dedicated workforce of over 5000 colleagues working in a diverse range of services over 55 sites and within people's homes. We strive to enable a welcoming workplace culture that builds and celebrates civility, inclusivity and diversity, while providing a sense of belonging and trust.
Annual staff surveys, regular Pulse surveys and other engagement opportunities provide our people with lots of opportunity to tell us about their experiences of working with us. In the latest staff survey, 61% of colleagues gave us their views. It was great to hear that:
- 72% of colleagues would recommend the Trust as a place to work, ranking us 1st for Provider Trusts in the South West region on this question.
- 76% would recommend the standard of care provided in our services if a friend or relative needed treatment, also ranking us 1st in the South West region.
- 81% said that care of patients and service users is the Trust's priority, compared with an average in comparable NHS Trusts in England of 64%.
This high-level overview shows we are in a healthy position, with higher scores than average for comparable organisations, alongside a great response rate, indicating good staff engagement. However, we also know we have plenty of room for improvement in many areas. To that end, we continue to prioritise and invest in our commitment to genuinely becoming a Great Place to Work with consistent top-quartile performance in the annual staff survey and Pulse surveys.
Job description
Job responsibilities
- Work with other members of the team to organise workload, work flexibly with team members across the County to cover the service
- The post holder will mainly communicate face to face with patients in their own homes whilst undertaking assessments. There will also be follow up telephone calls and letters when required.
- There may be times when the post holder will have to adapt their communication style to the audience when patients have difficulty in understanding.
- The post holder will be highly skilled in communicating effectively and be able to deal appropriately with complex and sensitive information.
The Trustis required towork in line with the Governments UK Visa and Immigration Rules and Regulations. For more information about sponsorship for certain roles, please visit -https://www.gov.uk/browse/visas-immigration/work-visas
Job description
Job responsibilities
- Work with other members of the team to organise workload, work flexibly with team members across the County to cover the service
- The post holder will mainly communicate face to face with patients in their own homes whilst undertaking assessments. There will also be follow up telephone calls and letters when required.
- There may be times when the post holder will have to adapt their communication style to the audience when patients have difficulty in understanding.
- The post holder will be highly skilled in communicating effectively and be able to deal appropriately with complex and sensitive information.
The Trustis required towork in line with the Governments UK Visa and Immigration Rules and Regulations. For more information about sponsorship for certain roles, please visit -https://www.gov.uk/browse/visas-immigration/work-visas
Person Specification
Qualifications
Essential
- Level one Registered General Nurse or Allied Health Care Professional
- Professional knowledge acquired through degree supplemented by post graduate diploma specialist training, experience, short courses plus further specialist training to masters equivalent level or equivalent.
- Current and valid registration with the relevant professional body
- Evidence of post-registration qualifications/experience at post graduate level in managing complex long-term conditions and frailty.
- Qualification in Physical Assessment and Clinical Reasoning (PACR)
- Valid Driving Licence
Desirable
- Pathophysiology and Diagnostic reasoning for Advancing Practice PADRAP qualification
- Qualification in, or willingness to work towards Independent Non-medical Prescribing,
- Qualification in, or willingness to work towards Facilitated Learning and Assessment in Practice (FLAP)
Experience
Essential
- Experience in managing a complex clinical caseload
- Experience in managing difficult situations that require advanced communication and negotiating skills
- Experience in managing clinical risks
- Experience of case management models of care including personalised goal setting, care planning and self-management plans and escalation plans
- Evidence in advanced comprehensive assessment including interpreting information, performing clinical interventions, diagnostics and analysing results.
- Evidence of long-term conditions case management in the wider nursing and allied health professional arena
Desirable
- Significant post registration experience spent in a variety of settings including the community
Person Specification
Qualifications
Essential
- Level one Registered General Nurse or Allied Health Care Professional
- Professional knowledge acquired through degree supplemented by post graduate diploma specialist training, experience, short courses plus further specialist training to masters equivalent level or equivalent.
- Current and valid registration with the relevant professional body
- Evidence of post-registration qualifications/experience at post graduate level in managing complex long-term conditions and frailty.
- Qualification in Physical Assessment and Clinical Reasoning (PACR)
- Valid Driving Licence
Desirable
- Pathophysiology and Diagnostic reasoning for Advancing Practice PADRAP qualification
- Qualification in, or willingness to work towards Independent Non-medical Prescribing,
- Qualification in, or willingness to work towards Facilitated Learning and Assessment in Practice (FLAP)
Experience
Essential
- Experience in managing a complex clinical caseload
- Experience in managing difficult situations that require advanced communication and negotiating skills
- Experience in managing clinical risks
- Experience of case management models of care including personalised goal setting, care planning and self-management plans and escalation plans
- Evidence in advanced comprehensive assessment including interpreting information, performing clinical interventions, diagnostics and analysing results.
- Evidence of long-term conditions case management in the wider nursing and allied health professional arena
Desirable
- Significant post registration experience spent in a variety of settings including the community
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
