Job responsibilities
To be a visible professional role model providing strong facilitative and effective clinical leadership and high quality care Identify existing community resources and discrepancies of care across the HCC area, including acute trusts and the North East London and Mid and South Essex ICS that provide holistic care for patients with haemoglobinopathies; resources that include Empowering patients and carers by providing health education enabling informed decisions about their care. Enhancing compliance with preventative actions such as vaccinations and prophylactic medications. Providing guidance on self-management to prevent exacerbation of patients condition to reduce incidences of acute episodes requiring admission to secondary care. Addressing social and lifestyle factors which impact on condition management and overall quality of life, directing to appropriate local support services and external agencies. Acting as a patient advocate through the application of ethical, legal, and professional knowledge and skills, considering the multicultural needs of the patient by identifying demographic factors that influence health care needs of this patient group. Providing targeted support to high-intensity users of secondary care including directing patients into existing NCL programmes for frequent ED attenders. Pre-contacting patients to reduce DNA rates to hospital. Promoting and enable implementation of individual care plans for patients in all settings. Advising on appropriate drug management at home, including dosages and information on non-pharmacological management techniques. Follow up on a regular basis to monitor effectiveness of the regimen and compliance. Utilising advanced prescribing skills within the guidance from NMC and Trust. Implementation of a patient outreach health education group programme, and organisation of patient led education sessions. To identify and advocate for a portfolio of patients with complex community needs who are high frequency users of acute and emergency hospital-based services, and require prolonged hospital stays, by delivering and coordinating home visits and support services with acute trust and community healthcare professionals. To provide guidance for complex management of chronic pain and acute pain flares managed at home and community practice by identifying those patients across NEL with greatest need, signposting multidisciplinary services and contributing to safe prescribing and medication practice and pathways of care to reduce use of emergency and acute hospital care To ensure that formal communication channels are established within and between community teams and professional care. To interpret local policies, health legislation and directives with regard to their impact on, and applicability to community care and ensure their effective implementation as appropriate. To identify and promote multi-disciplinary working within the community Build networks and signposting mechanisms enabling optimal access to and use of these existing resources Advocate for existing resources through engagement with hospital Trusts and ICS leads and managers Use areas of excellence identified in existing community resources to design strategies to develop these resources in areas lacking them, or cross-linking and signposting to enable shared use of resources Provide in-reach service to secondary care by identifying GPs and practice nurses with sickle cell expertise and interest to create a strategy to empower more community-based practitioners to train in areas of high prevalence for haemoglobinopathies Promote good clinical practice in line with evidence-based guidelines and policies. Work closely with HCC, SHT and LHT multidisciplinary haematology team, acute wards and day unit staff and primary care medical and nursing staff, to initiate timely early discharge planning and facilitate community services for early discharges. Support and develop community delivered nurse led clinics, telephone, or face to face, interpreting results, taking appropriate action, and feeding back into MDT meetings and reviews. Lead on community MDT discussions within the department and with other specialities. Support Virtual Ward programmes providing specialist assessment and advice. Ensure nursing practice is in accordance with the NMC code of conduct. Identify own training needs taking responsibility for maintaining own professional development, continuously reflecting on monitoring, evaluating, and improving own professional performance. Lead on training programme development for the service in the community. Participate in addressing the training needs of other health professional involved in the service, and other relevant services. Ensure that staff receive appropriate training and professional development in accordance with professional recommendations. Discuss and present performance. Future needs using individual performance review and keep up to date with developments in the speciality and with nursing in general Contribute and facilitate to the identification, dissemination, application of new technology and new knowledge in relation to best practice. Build trust with patients to enhance their overall healthcare experience. Communicate effectively with patients ensuring an individualised and equitable approach to all, taking in to account the complex and sensitive nature of condition management needs for red cell disorders. Develop and maintain close links with multidisciplinary colleagues in primary, secondary, and social care to support early referral and enhance continuity of care for patients. Utilise interpreting services for patients with a language barrier. Maintain accurate records regarding all patient contacts, including telephone consultations. Ensure that confidentiality and adherence to the Data Protection Act is maintained Develop robust and holistic community services, in conjunction with external partners, to offer sustainable and appropriate alternatives to hospital attendances. Attend and actively participates in meetings and conferences as appropriate ensuring you are fully conversant with current issues both within the Trust and within the specialty, locally and nationally. Empower, support, and inspire staff to improve standards and develop professional practice. Practice in an organised but flexible manner with the ability to respond to the unpredictable and challenging needs of the service including cross-site cover. Be responsible for ensuring complaints, both formal and informal, are responded to appropriately and that plans are formulated and followed through based on complaints data. Participate in division and healthcare governance activities. Be an active member of appropriate committees and working group, representing Nursing. Assess and agree needs and priorities for work streams and focus work to support those priorities. Map out programme of work. Responsibility for developing integrated, equitable, safe and effective pathways of care based in the community to support patients living with sickle cell disease and thalassaemia, supported by the HCC medical, nursing and managerial leads Responsible for coordinating and participating in the development of haemoglobinopathy service policies and standard operation procedures appropriate to the role. Provide measurable standards of community practice in pain management, prescribing and medication compliance and psycho-social care. Lead on data collection to enable service evaluation, ensuring it is accurate and submitted in a timely manner. Provide quarterly activity progress reports to the departmental management meetings. Produce other ad-hoc reports/updates as requested and required by the service. Analyse and interpret data to inform decisions around service provision and procedures. Monitor and coordinate the uploading of local patient accrual data in conjunction with other community services and hospital-based teams. Participate in the evaluation of new/alternative non-pharmaceutical products and deal with commercial companies. Attend local and regional meetings to share good practice and keep informed of changes to practice and national standards and targets. Ensure that quality, effectiveness, the management of risk, patient safety, and the experiences of patients, carers and staff are all actively monitored, managed, and improved. Identify and implement service specific audits and peer reviews which will underpin an evidence-based approach to practice and service excellence. Proactively lead on developing and implementing robust policies and audit processes relating to patient services and nursing services in general (this includes patient/family surveys/feedback/comments Develop strategies to evaluate practice from healthcare governance, quality, cost effectiveness, risk management and clinical effectiveness perspective. Participate in the audit and evaluation of community nursing care and practice-reporting and presenting as required.
