Job responsibilities
Work with patients (who have consented) and discuss their needs to ensure their care plan is being followed, provide support and guidance as required and report any issues with complianceHave up to date knowledge of local services and be able to use available resources effectively.Identify and report any new problems, changes or concerns in the patients or carers circumstances to the GP and Clinical Lead / HCP/Line ManagerEnsure patient understanding of the system and coordinate timely onward referral as per the care plan, and as necessary to appropriateHealth and Social Care ServiceWork collaboratively with colleagues in Primary care to actively seek out patients who will benefit from Telehealth and coordination to avoid unplanned hospital admissions, reduce the length of hospital stays and support and promote independence at home and facilitate discharges as appropriate
Support including self-management
Support patients to be as independent as possible by facilitating range of self-management strategies i.e., available from other sectors.Support GPs to establish effective working relationships with patients, their families and carers. This will include promoting individual rights and recognising and respecting their contributions to care planning and delivery.The person needs to form professional relationships with clients, and communicate with them in a way that respects their views, autonomy and culture and provide an integrated care approach.The individual needs to be able to liaise with relatives, carers, medical staff, allied health staff and those within the multidisciplinary team to obtain or feedback information relating to the patients care.To be able to contribute towards the teams vision and attend meetings and events to promote the servicePerson must understand and apply the need for confidentiality in all aspects of patient interactions.Person needs to be legally accountable for all aspects of own work.Person needs to use clinical knowledge and life skills to build up a rapport with the clients, to engage with them and motivate them to engage with their own care.
Knowledge
Being aware of national and local policy that impacts upon the health and well-being of patients with complex chronic conditions.Working with the multi-disciplinary team promoting self-care for patients with long term conditions.Working with patients and their families to plan for and improve last years of life care, ensuring that choices are reflected in personalised care plans
Administration
The person needs to ensure confidentiality of client information is maintained.The person needs to ensure to adhere to data governance including documentationThe person needs to take responsibility for the maintenance of equipment used within the clinical setting and to report any malfunction or damage.The person needs to attend service/team meetings as requested and participate in clinical governance and service improvement work, including audit activity or special projects as applicable.The individual has a responsibility to contribute to the smooth running of the service and play an active part as a team member.
Management and Record Keeping
- Person needs to maintain legible, accurate, contemporaneous clinical records.
- Ability to understand and employ a set of non-specific skills to meet the psychological needs of service users with mental health needs through care planning and risk managementstrategies.
- The individual needs to use strategies to overcome barriers to understanding when communicating with clients who do not have English as a first language, or those who have difficulty understanding or expressing themselves clearly, due to stroke or dementia illness.
- The person needs to able to work without direct supervision in the implementation of programmes of care in order to meet prior agreed goals; evaluate the effectiveness of intervention, and, make any changes in consultation with senior members of team
- Education and Supervision Responsibilities:
- The individual needs to attend regular supervision sessions with their identified mentor.
- The person needs to participate in the individual performance review system. To contribute to identification of training needs and the development of a personal development plan to address these.
- The person needs to keep a record of learning from training and development activities, and develop evidence of their competence within the job.
- The person needs to attend relevant course/study days and to share information gained or skills learnt with other staff within the service.
- The individual needs to be aware of, and comply with Community Health Newham and East London Foundation Trust policies and procedures, following the induction process