Job summary
Improve discharge planning and continuity of care to optimise patients and reduce risk of readmission e.g., integrated acute and community heart failure services, improve 2 week follow up, patient education and supported self-management etc.
Continued collaboration and joint working of all providers to further develop the use of DOCCLA within the specialty including a pathway of referral from the established MDT. This work will create and embed a pathway between primary and secondary care.
Pathways will be in place to support these patients and embedded for clinicians to follow. This work stream can then connect with the wider virtual ward plans for cardiac patients within BLMK and the funding streams available and the longer terms plans of central monitoring of all three work streams of frailty, respiratory and cardiac.
Once stabilised and discharged from DOCCLA, pathways will also include palliative and long term condition follow up, utilising established teams and resources in Primary and Community services.
Patients will be educated and empowered to monitor their symptoms for a period of time following hospital discharge using DOCCLA. This knowledge will enable them to identify early any worsening symptoms and onward self-referral back to the appropriate team.
Should we receive a high number of applications we reserve the right to close this vacancy at any point after 25th June 2025.
Main duties of the job
Using highly specialised skills devise individualised management plans for patients referred to community heart failure service, including palliative care planning where appropriate
Provide education to patients on nature of treatment, side effects and expected outcome.
Empower patients to manage their own condition to encourage independence.
Undertake nurse led clinics.
Undertake assessments and formulate treatment plans for the management of heart failure.
About us
Rated 'Outstanding' by the Care Quality Commission, we are proud to provide high quality innovative services across most of the east of England that enable people to receive care closer to home and live healthier lives.
There's one reason why our services are outstanding - and that's our amazing staff who, for the seventh year running, rated us incredibly highly in the national staff survey.
If you share our passion for innovative and high-quality care delivery, then please submit your application and join us on our exciting journey as a leading-edge specialist community provider. All are welcome to apply and our promise to you is a culture which prioritises staff engagement and development.
Job description
Job responsibilities
To develop and facilitate the improvement of care and experience for patients with heart failure in the community.
To provide individualised evidence based care for heart failure patients and their carers which empowers patients to take an active role in their own care.
To work with primary and secondary care to reduce the need for unplanned admissions to hospital.
To play a key role in the development and delivery of national and local priorities for heart failure, working collaboratively with other health professionals through cross boundary working e.g. NICE guidelines.
To act as a resource to all members of the multidisciplinary team and provide specialist advice concerning all aspects of heart failure management.
To develop and deliver education and training for multidisciplinary team and all service users.
Job description
Job responsibilities
To develop and facilitate the improvement of care and experience for patients with heart failure in the community.
To provide individualised evidence based care for heart failure patients and their carers which empowers patients to take an active role in their own care.
To work with primary and secondary care to reduce the need for unplanned admissions to hospital.
To play a key role in the development and delivery of national and local priorities for heart failure, working collaboratively with other health professionals through cross boundary working e.g. NICE guidelines.
To act as a resource to all members of the multidisciplinary team and provide specialist advice concerning all aspects of heart failure management.
To develop and deliver education and training for multidisciplinary team and all service users.
Person Specification
Qualifications and Training
Essential
- Registered General Nurse
- Educated to degree level or equivalent
- Independent nurse prescriber or willingness to undertake course
- Mentor/Preceptor/998 - Teaching & Assessing Qualification
- Specialist post -graduate qualification in a relevant subject to post graduate or masters level.
Desirable
- Community Nursing qualification
- Management experience
- Clinical assessment and skills course
Experience
Essential
- Significant and in-depth post registration experience
- Ability to work across organisational boundaries
- Understanding of local and national developments within the NHS
- Understanding of Clinical Governance
- Ability to safeguard and promote the welfare of vulnerable adults
- In highly stressful situations keeps own feelings in check, takes constructive action and calms others down
- Accepts responsibility and accountability for own work and can define the responsibilities of others
Desirable
- Community or Practice Nurse experience and experience developing and implementing new services
- General cardiac background and significant Experience in Heart Failure Experience in Palliative care
Knowledge and Skills
Essential
- Ability to prioritise a constantly changing caseload
- Good interpersonal skills
- Clinical assessment skills
- Appreciates the significance of safeguarding and interprets this accurately for vulnerable adults whatever their life circumstances
- Shows a realistic appreciation of the challenges of working with vulnerable adults
- Has a realistic knowledge of personal strengths and areas for development
- Understands the principle of confidentiality
Person Specification
Qualifications and Training
Essential
- Registered General Nurse
- Educated to degree level or equivalent
- Independent nurse prescriber or willingness to undertake course
- Mentor/Preceptor/998 - Teaching & Assessing Qualification
- Specialist post -graduate qualification in a relevant subject to post graduate or masters level.
Desirable
- Community Nursing qualification
- Management experience
- Clinical assessment and skills course
Experience
Essential
- Significant and in-depth post registration experience
- Ability to work across organisational boundaries
- Understanding of local and national developments within the NHS
- Understanding of Clinical Governance
- Ability to safeguard and promote the welfare of vulnerable adults
- In highly stressful situations keeps own feelings in check, takes constructive action and calms others down
- Accepts responsibility and accountability for own work and can define the responsibilities of others
Desirable
- Community or Practice Nurse experience and experience developing and implementing new services
- General cardiac background and significant Experience in Heart Failure Experience in Palliative care
Knowledge and Skills
Essential
- Ability to prioritise a constantly changing caseload
- Good interpersonal skills
- Clinical assessment skills
- Appreciates the significance of safeguarding and interprets this accurately for vulnerable adults whatever their life circumstances
- Shows a realistic appreciation of the challenges of working with vulnerable adults
- Has a realistic knowledge of personal strengths and areas for development
- Understands the principle of confidentiality
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).
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
