Black Country Integrated Care Board

Complex Care Nurse Assessor - Discharge to Assess (D2A)

This job is now closed

Job summary

We are looking for passionate and experienced Band 7 Nurses to join our dedicated team at the award-winning Integrated Discharge Hub in Sandwell, where we are committed to providing exceptional care and support to our community.

The Hub brings together practitioners from across health and social care to support patient flow across acute and community. Working with skilled and experienced practitioners, the successful candidates will be pivotal in preventing unnecessary hospital stays and readmissions to reduce the burden on acute beds and ensure patients receive the right care at the right time.

It is an exciting opportunity that would suit someone who would like to be able to work flexibly across Continuing Healthcare and the Integrated Discharge Hub. The postholder can expect to be part of a dynamic, fast paced, multi-disciplinary team, playing an integral role in influencing and supporting pathway decisions.

The role involves participation in daily stakeholder engagement, with a requirement to develop and maintain good collaborative working relationships and a commitment to improving patient experience.

The Integrated Discharge Hub operates 8am-8pm, 7 days per week.

Main duties of the job

Key Responsibilities:

Provide Continuing Healthcare expertise within the Integrated Care Hub.
Support triage and care navigation
Coordinate high-quality patient care.
Undertake healthcare assessments and develop support and care plans in collaboration with other healthcare professionals.
Provide clinical support to ensure best practices.
Engage in continuous professional development and training.

Requirements:

Registered Nurse with valid NMC registration.
Experience in a similar role, preferably within an integrated care setting.
Work a flexible 7-day rota to ensure comprehensive support
Strong leadership and management skills.
Excellent communication and interpersonal abilities.
Ability to work collaboratively within a multidisciplinary team.
Commitment to ensuring patients receive high-quality care outcomes.

About us

The Black Country Integrated Care Board (ICB) is a statutory NHS organisation responsible for developing a plan for meeting the health needs of 1.26 million people in the Black Country. We manage the NHS budget for the area (Dudley, Sandwell, Walsall and Wolverhampton) and we are responsible for planning and buying Primary Medical Services (GPs), dental, optometry and pharmacy services.

Working for the ICB means you are making a difference to the lives and health of people in the Black Country.

We are part of the Black Country Integrated Care System (ICS), known as Healthier Futures, which is a partnership of organisations working together to bring health and social care services closer together for the good of our communities. We support the ICS vision for a healthier place with healthier people and healthier futures.

The ICB has five core values that underpin the way we work and help to guide our actions and the decisions we make for local people and communities. These are compassion, inclusivity, integrity, fairness and trust.

We are an equal opportunities employer who actively supports and encourages increasing the diversity of our employees, and welcome applications from people with transferable skills gained through experience across the full range of health and social care settings.

We are also a bronze award holder under the Defence Employer Recognition Scheme (ERS). The ERS recognises commitment and support from UK employers for defence personnel.

Date posted

11 October 2024

Pay scheme

Agenda for change

Band

Band 7

Salary

£46,148 to £52,809 a year

Contract

Permanent

Working pattern

Full-time, Flexible working

Reference number

D9118-24-0066

Job locations

Sandwell Council House

Freeth Street

Oldbury

B69 3DE

Job description

Job responsibilities

The post holder will be required to provide a high-quality resource of professional advice, guidance and expertise to members of the Individual Care Team, ICB and wider health and social care economy
Autonomously manage a case load of individuals with highly complex health needs providing significant clinical guidance to providers.
Ensure that all assessments are holistic in nature and utilise The National Framework for NHS Continuing Health Care.
To have an expert level of knowledge regards The National Framework and its application in practice. To be able to impart this knowledge to a variety of audiences.
To provide complex and sensitive information to patients, relatives/ representatives and often work in potentially hostile environments; relaying difficult decisions regarding care provision and managing patient and family expectations.
Provide continuity of care throughout the period of care and support. This will encompass close working with health and social care professionals and care providers.
Attend all meetings related the patient which may impact on the care provision and costs to meet identified needs
Liaise with multiple professionals involved in the patients care to ensure that a comprehensive understanding of all identified needs is available. Ensuring that each patient has a care plan that addresses all their identified needs and can be used to assist assessors when completing CHC assessments/reviews.
Present comprehensive written reports to ICB Eligibility Panel following any reviews completed once patients are in receipt of agreed care provision that identify a change in the level of care required. This includes being able to demonstrate improvements that may result in a reduction of care provided or a change the patients eligibility for NHS CHC.
To be responsible for negotiating care package costs and the monitoring of packages of fully funded care which are in excess of £1000 per week. To be responsible for ensuring these care packages are reviewed to an agreed time scale, identified by the Head of Service and that these are recorded on the ICB database.
Identify and process any safeguarding and quality of care issues and take appropriate action to ensure that peoples welfare is protected and that the quality and standard of services provided are at a level that is in line with ICB required standards. Close liaison with the ICB Quality Team is necessary to ensure ICB funded individuals are in receipt of high quality, safe care.
Ensure Mental Capacity Act is considered and ensure relevant processes are followed eg. Best Interests, DOLs
Develop and maintain effective working relationships with clinicians, general practitioners and providers in order to ensure continuity of care and address patient needs.
Provide a high-quality resource of professional advice, guidance and expertise to the ICB and partner agencies in addressing the needs of individuals with complex health needs.
Liaising with a variety of providers and arranging assessment of patients in order that the most appropriate placement/provider is identified.
Provide information and support to the senior managers when considering the most appropriate provider to address a patients identified needs and to act autonomously when required to agree care packages in excess of the usual ICB cost.
To maintain a formal record of all cases and ensure that all relevant clinical information is available and updated regularly, both electronically and in patient files.
Support the Head of CHC in working with partner agencies and other stakeholders in developing the local market for services to ensure that it reflects the requirements of individuals and is able to meet current and future needs
To call and chair multi-disciplinary meetings, including case conferences and discharge meetings to ensure continuity of care across agencies; thus improving patient and family experience.
Deputise for the Lead Nurse as required
Provide data in order that the ICB can continuously monitor care delivery and identify how performance of providers can be improved. Working closely with colleagues in the ICB Quality Team to assure the quality of care received by NHS funded individuals.
To have budgetary monitoring responsibilities and to ensure that the Head of Service is informed of any identified budget pressures or financial risks that may impact on the overall service budget. The post holder will need to demonstrate both quality of care and value for money in all placements.
To develop policies and procedures, as requested, which will support the overall delivery of NHS Funded Care within the ICB.
To contribute to and deliver training on CHC and FNC to a variety of audiences particularly in health and social care.
To provide professional support and mentoring to the nurse assessors within the team and provide additional support and training as required by the Lead Nurse.
To work within the NMC Code/Professional Code** and to meet requirements for revalidation.
To undertake and comply with all mandatory training.

Job description

Job responsibilities

The post holder will be required to provide a high-quality resource of professional advice, guidance and expertise to members of the Individual Care Team, ICB and wider health and social care economy
Autonomously manage a case load of individuals with highly complex health needs providing significant clinical guidance to providers.
Ensure that all assessments are holistic in nature and utilise The National Framework for NHS Continuing Health Care.
To have an expert level of knowledge regards The National Framework and its application in practice. To be able to impart this knowledge to a variety of audiences.
To provide complex and sensitive information to patients, relatives/ representatives and often work in potentially hostile environments; relaying difficult decisions regarding care provision and managing patient and family expectations.
Provide continuity of care throughout the period of care and support. This will encompass close working with health and social care professionals and care providers.
Attend all meetings related the patient which may impact on the care provision and costs to meet identified needs
Liaise with multiple professionals involved in the patients care to ensure that a comprehensive understanding of all identified needs is available. Ensuring that each patient has a care plan that addresses all their identified needs and can be used to assist assessors when completing CHC assessments/reviews.
Present comprehensive written reports to ICB Eligibility Panel following any reviews completed once patients are in receipt of agreed care provision that identify a change in the level of care required. This includes being able to demonstrate improvements that may result in a reduction of care provided or a change the patients eligibility for NHS CHC.
To be responsible for negotiating care package costs and the monitoring of packages of fully funded care which are in excess of £1000 per week. To be responsible for ensuring these care packages are reviewed to an agreed time scale, identified by the Head of Service and that these are recorded on the ICB database.
Identify and process any safeguarding and quality of care issues and take appropriate action to ensure that peoples welfare is protected and that the quality and standard of services provided are at a level that is in line with ICB required standards. Close liaison with the ICB Quality Team is necessary to ensure ICB funded individuals are in receipt of high quality, safe care.
Ensure Mental Capacity Act is considered and ensure relevant processes are followed eg. Best Interests, DOLs
Develop and maintain effective working relationships with clinicians, general practitioners and providers in order to ensure continuity of care and address patient needs.
Provide a high-quality resource of professional advice, guidance and expertise to the ICB and partner agencies in addressing the needs of individuals with complex health needs.
Liaising with a variety of providers and arranging assessment of patients in order that the most appropriate placement/provider is identified.
Provide information and support to the senior managers when considering the most appropriate provider to address a patients identified needs and to act autonomously when required to agree care packages in excess of the usual ICB cost.
To maintain a formal record of all cases and ensure that all relevant clinical information is available and updated regularly, both electronically and in patient files.
Support the Head of CHC in working with partner agencies and other stakeholders in developing the local market for services to ensure that it reflects the requirements of individuals and is able to meet current and future needs
To call and chair multi-disciplinary meetings, including case conferences and discharge meetings to ensure continuity of care across agencies; thus improving patient and family experience.
Deputise for the Lead Nurse as required
Provide data in order that the ICB can continuously monitor care delivery and identify how performance of providers can be improved. Working closely with colleagues in the ICB Quality Team to assure the quality of care received by NHS funded individuals.
To have budgetary monitoring responsibilities and to ensure that the Head of Service is informed of any identified budget pressures or financial risks that may impact on the overall service budget. The post holder will need to demonstrate both quality of care and value for money in all placements.
To develop policies and procedures, as requested, which will support the overall delivery of NHS Funded Care within the ICB.
To contribute to and deliver training on CHC and FNC to a variety of audiences particularly in health and social care.
To provide professional support and mentoring to the nurse assessors within the team and provide additional support and training as required by the Lead Nurse.
To work within the NMC Code/Professional Code** and to meet requirements for revalidation.
To undertake and comply with all mandatory training.

Person Specification

Experience

Essential

Significant experience gained over a number of years in a complex, multi-disciplinary environment
Extensive experience of case management with service users who have complex health needs
A clear knowledge and understanding of The National Framework for NHS Continuing Health Care and its application in practice
An understanding of the Mental Capacity Act 2005 and its application
An understanding of commissioning for complex health needs in the context of NHS Continuing Healthcare
Experience of monitoring a budget and understanding of financial systems and processes

Personal Qualities

Essential

Self-motivated and enthusiastic
Adaptability, flexibility to work and ability to cope with uncertainty and change
Works well with others, is positive and helpful, listens, involves, respects and learns from the contribution of others
Consistently looks to improve what they do, look for successful tried and tested ways of working, and also seeks out innovation
Actively develops themselves and supports others to do the same
Understanding of and commitment to equality of opportunity and good working relationships
Professional, calm and efficient manner

Skills and Knowledge

Essential

High level of working knowledge of the relevant legislation and theories underpinning the provision of services to the relevant client group
Demonstrable experience and knowledge of current key policies and priorities within the NHS, especially within Clinical commissioning Groups
A clear knowledge and understanding of service provision available locally, regionally and nationally for the client group
Understanding of relevant current NHS and social care market mechanisms
Good working knowledge of adult safeguarding
Awareness of Data Protection and confidentiality issues
Working knowledge of Microsoft Office with standard keyboard skills
Effective interpersonal and negotiation skills enabling effective communication with clients, other professionals, colleagues, partner agencies, providers and carers.
Excellent written and verbal communication including providing and receiving complex, sensitive or contentious information
Excellent time management skills
Ability to prioritise and to work effectively on own initiative
Ability to work in hostile environments and deal with conflict on a regular basis
Understanding of the commissioning/ procurement process for adults continuing health care packages

Qualifications

Essential

Relevant degree/professional qualification in Nursing*** (local areas may differ/could be Social Work))
Evidence of continuous professional development
Educated to degree level or equivalent level of experience of working at a senior level in a specialist area.

Person Specification

Experience

Essential

Significant experience gained over a number of years in a complex, multi-disciplinary environment
Extensive experience of case management with service users who have complex health needs
A clear knowledge and understanding of The National Framework for NHS Continuing Health Care and its application in practice
An understanding of the Mental Capacity Act 2005 and its application
An understanding of commissioning for complex health needs in the context of NHS Continuing Healthcare
Experience of monitoring a budget and understanding of financial systems and processes

Personal Qualities

Essential

Self-motivated and enthusiastic
Adaptability, flexibility to work and ability to cope with uncertainty and change
Works well with others, is positive and helpful, listens, involves, respects and learns from the contribution of others
Consistently looks to improve what they do, look for successful tried and tested ways of working, and also seeks out innovation
Actively develops themselves and supports others to do the same
Understanding of and commitment to equality of opportunity and good working relationships
Professional, calm and efficient manner

Skills and Knowledge

Essential

High level of working knowledge of the relevant legislation and theories underpinning the provision of services to the relevant client group
Demonstrable experience and knowledge of current key policies and priorities within the NHS, especially within Clinical commissioning Groups
A clear knowledge and understanding of service provision available locally, regionally and nationally for the client group
Understanding of relevant current NHS and social care market mechanisms
Good working knowledge of adult safeguarding
Awareness of Data Protection and confidentiality issues
Working knowledge of Microsoft Office with standard keyboard skills
Effective interpersonal and negotiation skills enabling effective communication with clients, other professionals, colleagues, partner agencies, providers and carers.
Excellent written and verbal communication including providing and receiving complex, sensitive or contentious information
Excellent time management skills
Ability to prioritise and to work effectively on own initiative
Ability to work in hostile environments and deal with conflict on a regular basis
Understanding of the commissioning/ procurement process for adults continuing health care packages

Qualifications

Essential

Relevant degree/professional qualification in Nursing*** (local areas may differ/could be Social Work))
Evidence of continuous professional development
Educated to degree level or equivalent level of experience of working at a senior level in a specialist area.

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.