Job responsibilities
The
post holder will be required to provide clinical case management to a group of
patients who meet the Trust identified criteria, who have long term conditions
and other complex medical and social problems. They will develop the clinical
case management role and function across health and social care organisations.
The primary function of the role is to maximise the patients health,
clinically assess and treat patients in a defined group and reduce risks that
contribute to ill health, thereby reducing unnecessary admissions to acute
services, reducing demand on GP time and facilitating the delivery of
efficient, effective, co-ordinated and timely high-quality care to patients.
Duties and Responsibilities Clinical Matron
1.
Maximise
independence by supporting people with long term conditions and highly complex
needs to remain in their own homes as appropriate, by utilising and
commissioning available resources.
2.
Undertake
clinical assessment and provide treatment for patients within the defined group.
3.
Link with
existing services to facilitate early discharge from hospital and prevent
re-admission.
4.
Develop
Partnerships and joint working within the local health and social care economy.
5.
Work
collaboratively across organisation boundaries to support the effective and
co-ordinated provision of social care and health care services.
Clinical
Requirements:
6. Conduct a comprehensive health and social care
assessment, utilising any current information in order to develop an
individualised plan of care for patients within a defined group. This will
include:
Review of health
assessment including medical history
Physical examination
Assessment and review
of medication
Prescribing in conjunction
with management plans
Making referrals for
diagnostic tests
Functional /cognitive
assessment
Assessment of social
care needs.
7.
Develop,
monitor, and manage the plan of care in collaboration with the primary health
and social care team and others through:
Application of clinical
knowledge about long term conditions
Analysis of symptoms
and data
Identification of risk
factors associated with exacerbation of patients condition
Recognition of early
signs and symptoms of acute illness.
Involving patients and
carers in the development of the care plan and ensuring that their views and
abilities are reflected.
Documentation of
progress and continuous reassessment
Referral and
investigation.
8. Set up and actively participates
in case review to evaluate the outcomes of care plans including social care
needs.
9. Co-ordinate care and treatment to
avoid fragmentation, duplication, and delay in the least intensive setting
appropriate to the patients needs by:
Prioritisation and co-ordination
of multiple health and social care needs
Referrals to specialist services
Ensuring effective communication
and sharing of appropriate information amongst professionals to avoid
conflicting treatments.
Integration across health and social
care (inc. voluntary sector and housing)
Identifying deficiencies in
service provision and addressing these as appropriate (ie through commissioning
services for individuals)
Understanding and working through
entitlements to social care and necessary financial assessments.
10. Be aware of and adhere to, the Professional bodies Standards for
administration of Medicines Act 1992, and the Misuse of Drugs Act 1971.
Leadership
Requirements
11.
Lead the
process of identifying their caseload through interpretation of the information
available on the health needs of the locality in which they are based and
contribute to the collection of data to monitor outcomes measures for the
caseload
12. Participate in the development of
case management across the Trust.
13. Provide clinical leadership and
mentoring to those staff developing into a case management role.
14. Make, implement, and communicate
changes to clinical practice as necessary in relation to case management.
15.
Challenge
professional and organisational boundaries to ensure that the Case Management
role is focused on meeting the needs of service users, thus promoting
continuity of high-quality patient centred health and social care.
16.
Acts as
an advocate and champion for patients in a variety of forums and professional
groups and challenges attitudes and behaviour.
17.
Act as a
role model so that patients receive the most effective care possible through:
Encouraging
optimum management of long-term conditions to ensure that the patient is
functioning at the most independent level possible
Acting in
patients interests at all times.
18.
Contributing
to the development of policy and services to reflect the needs of the patient
caseload.
MANAGERIAL
RESPONSIBILITIES
19. Manage the complex clinical and
social care interventions of individuals within an identified patient group on
an ongoing basis.
20. Undertake risk assessment in
relation to individuals within the client group.
21.
Monitor
and respond to the development of changing clinical and social situations with
the identified patient group without recourse to others where possible.
22. Ensure the safe management of care and service delivery.
23. Line manage a defined team of staff, including performing
appraisal, personal development reviews and the application of staff management
procedures.
Service Development
Requirements
24. Encourage patient and carer
participation in case management through:
The
provision of information about disease prevention, progression, and outcomes.
Ensuring
that services are accessible to increase patient confidence
Empowering
the patient to self manage whenever possible.
25. Contribute to the development of
role and service redesign in long term condition management.
Analytical and Information Requirements
26.
The
postholder will utilise data and data tools (including databases) to produce
appropriate monitoring reports on both patient care and service outcomes and
produce appropriate communication for patients.
Clinical Governance Requirements
27.
Participate
in individual and group clinical supervision and action learning sets, and to
take responsibility for developing own learning.
28.
Participate
in research and audit relating to long term conditions management.
29.
Ensure
systems are in place for ongoing review and assessment of care provision and
delivery.
30.
Improve
quality via Clinical Governance, Essence of Care and Clinical Supervision, by
working closely with colleagues to address competency levels within the
service.
31.
Report
any incidents through application of trust policies.
32.
Participate
in patient satisfaction reporting to improve patient care.
Education and Training Requirements
33.
Promote
formal and informal training to pre and post registration health and social
care professionals in relation to integrated working and provide mentorship and
teaching to others developing a case management function.
34.
Participate
in the induction of new staff.
35.
Provide
education, advice and support to health and social care staff, people with long
term conditions and their carers in both community and acute settings.
36.
Maintain
up to date knowledge and competence in line with professional and service
requirements and demonstrate critical thinking, decision making and reflective
skills to ensure own professional development.
Communication/Relationship Requirements
37.
Liaise with patients and
carers, community and specialist nursing and other health professionals, GPs,
acute colleagues, social care colleagues and the voluntary/charitable and
non-NHS sector.
38.
Work with
patients and carers to:
Ensure that their values, beliefs
and views are reflected in the case management plan
Encourage active participation in
case management
Ensure that health advice and
social care is provided in a professional, accessible, and supportive way.
39.
Work with
other professional and statutory groups involved in case management to:
Ensure that there is consistent
and high-quality implementation of care
Avoid duplication, delay, or
distress to patient
Ensure
that record keeping is consistent with Trust and professional standards.
40. Communicate at all levels of the
organisation to a variety of health and social care professionals to provide
best outcomes for patients.
