Job responsibilities
Job Summary
The postholder is accountable to the Head of All Age Continuing Care and Individual Commissioning and responsible to the Case Management Team Manager. The postholder will be supported by a Team Leader.
The postholder will be expected to work across the breadth of specialties according to their competency levels. For example, all of the team will be expected to cover Personal Health Budgets (PHB) or appeals, but only those competent to cover childrens or Learning Disabilities (LD) would be expected to do so.
The postholder will take an active role and work as an expert clinician in facilitating and/or providing professional support, commissioning and case management of patients eligible for NHS Continuing Care, NHS Funded Nursing Care, CYP Continuing Care, those in receipt of joint or integrated funding and patients subject to various sections of the Mental Health Act This will encompass patients with complex physical, mental health and learning disability needs.
The postholder will have case management responsibility for a group of assigned patients and be responsible for ensuring that their health and care needs are met and regularly reviewed in line with local and national requirements and undertake eligibility assessments as indicated.
The postholder will undertake formal and informal teaching and training as needed. The candidate will possess expert knowledge and understanding of the process and commissioning approval system related policy and procedures relevant to the role.
The postholder will provide representation to a variety of multidisciplinary team meetings and panels.
The postholder will support teams to ensure that the portfolio of tasks/projects are planned, managed and delivered effectively.
The postholder will support and inform the targeting of resources, monitoring, implementation and evaluation of the tasks/projects by providing high quality support including complex information and analysis, communications and stakeholder management
The postholder will ensure accurate and open communication and co-ordination with a range of organisations and individuals.
The postholder will be a key member of the team as well as supporting effective communication and stakeholder management, both internally and externally
The postholder will ensure PHBs are promoted and implemented for their case load.
The postholder will undertake all required clinical and commissioning activity for patients on their caseload including following the DOLS process and once implemented Liberty Protection Safeguards (LPS), including undertaking mental capacity assessments, Court of Protection requirements and all requirements under the LPS legislation.
Key Working Relationships
The post holder will need to build and maintain constructive working relationships with internal and external stakeholders, including but not limited to:
Individual Commissioning management team
Individual Commissioning team members
Safeguarding teams
Local Authority
Service users and relatives
Solicitors and other legal representatives
NHSE/I
Care providers from all sectors
NHS STW colleagues
Educational establishments
Finance team
Commissioning team
Matrix work across all other teams to address interdependencies and ensure alignment of mutual objectives.
External consultancy, as required (this list is not exhaustive).
Key Duties & Responsibilities
The postholder will manage the co-ordination and monitoring of complex packages of care and NHS funded placements. It will be necessary to work closely with patients and their relatives ensuring that they understand the process, the eligibility criteria to be applied, and to provide empathy to patients.
The postholder will have a flexible approach to care and will work across inter-agency boundaries, maintaining good communication and liaison skills with all professionals and members of the public.
The postholder will undertake care reviews for people whose care is fully or partially funded by the NHS ensuring patient focused support and facilitating the most appropriate and cost-effective pathway for individual care.
The postholder will lead the management of packages of care for people in a variety of care and support settings.
The job description and person specification are an outline of the tasks, responsibilities and outcomes required of the role. The job holder will carry out any other duties as may reasonably be required by their line manager.
The job description and person specification may be reviewed on an ongoing basis in accordance with the changing needs of the Department and the Organisation.
Operational Responsibility
To manage a defined caseload undertaking responsibilities as delegated by the Team Leader/Manager - this will include the routine management of complex cases and the planning, organising and commissioning of specialised care packages ensuring the maintenance of accurate records.
To participate in the assessment, monitoring, review and complaints procedures of individuals with varying levels of complex needs whose care is managed in their own homes or in care settings.
To assist or lead (depending on who is the responsible commissioner) in the co-ordination of complex care packages involving members of the multi-disciplinary / multi-professional team as required.
To assist in the collaboration and the co-ordination of the review and assessment process and to undertake reviews and assessments, including formal eligibility assessments as indicated.
To undertake needs portrayal and retrospective assessments for PUPOC and appeals.
To practice at all times in a manner that is within the NMC Code of Conduct and Guidelines or equivalent for specialist health profession.
To practice at all times within a clinical governance framework that promotes quality.
To co-ordinate and commission complex care packages involving members of the multi-disciplinary /
multi-professional team
Financial and Physical Resources Responsibility
To support and inform teams on the targeting of resources, monitoring, implementing, evaluating and delivery of plans by providing sophisticated, high quality information and analysis.
To continually strive for delivering project/function/patient outcomes, value for money and greater efficiency.
To contribute to the financial delivery of the service ensuring it is cost effective and delivered on time.
To commission care to meet individual patient need and ensure best value, least restrictive care is achieved.
To work in collaboration with all providers of care to negotiate packages ensuring optimal value for money and advise on needs for market development purposes
Human Resources Responsibility
To provide specialist training, advice and support on own role/responsibilities across NHS Shropshire, Telford and Wrekin and the wider system.
To participate in the recruitment process of support staff.
To be accountable for own professional development and to participate in performance review.
To attend relevant training and staff meetings as required including participation in nursing and clinical development across NHS Shropshire, Telford and Wrekin.
To commit to undertake clinical supervision.
Information Management Responsibility
To contribute to the review and development of existing information management systems and contribute to the development of an integrated approach.
To maintain accurate and comprehensive clinical records.
To participate in and undertake audits and support the implementation of recommended actions.
To update, maintain, organise, gather and analyse information to predict/meet future organisational and team needs by identifying best professional practice.
To carry out timely and accurate information analysis and reporting on agreed areas of portfolio
To actively support and contribute to the development of key performance indicators for the successful assessment of performance.
Planning and Organisation Responsibility
To plan own workload and diary to ensure local, national and statutory targets and deadlines are met.
To undertake complex clinical assessment and care planning to ensure patient need is met and that where appropriate, step-down/discharge is planned and co-ordinated to ensure patient need is met in the least restrictive way.
To work with members of the team and key stakeholders to investigate the causes of any variance from plan/delivery targets and contribute to the implementation of solutions.
Policy and Service Development Responsibility
To contribute to the strategic planning recommending adjustments, as necessary.
To support implementation of strategic modernisation/service improvement, public health, workforce or commissioning strategies and any associated action plans, in accordance with the agreed priorities of the team
To contribute to the development of performance and governance strategies and the development and implementation of improvement programmes
To deliver against objectives, achieving quality outcomes, prioritising own workload and working to tight deadlines.
To propose changes to own function, informing policy and making recommendations for other projects delivery.
Research and Development Responsibility
To be accountable for own professional development and to participate in performance review.
