Community Matron
- Employer
- Bridgewater Community Healthcare NHS Foundation Trust
- Location
- Widnes
- Salary
- £50,952 to £57,349 a year
- Closing date
- 29 Sep 2023
View more
- Profession
- Nurse, Mental health, Mental health nurse, Community nurse, Mental health nurse - community, Community mental health nurse
- Grade
- Band 8A
- Hours
- Full Time
You need to sign in or create an account to save a job.
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.
Main duties of the job
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
About us
At Bridgewater, our PEOPLE values shape how we deliver our NHS services in your local community.
They help us deliver our mission to improve local health and promote wellbeing in the communities we serve.
After all, values are about people and they were created in partnership with our staff to reflect what they felt was important to them
Here at Bridgewater our shared values flow through the organisation.
P- Person-centred-We are passionate about individual needs and promote independence in the healthcare we provide..
E- Empowered- We empower our people and encourage new ideas to deliver and create improvements in community care.
O- Open and Honest -We behave in a way that develops relationships based on trust, openness, honesty and respect.
P- Professional-We support our people, so everyone has the right skills and training to deliver outstanding patient care.
L- Locally Lead -We are always learning about our communities and show great pride in being a local provider of health and care.
E- Efficient -We use our resources wisely to provide sustainable and value for money healthcare for our patients.
Unfortunately, we do not hold a sponsor licence for working Visas.
Job description
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.
Person Specification
Qualifications
Essential
Desirable
Experience
Essential
C9835-HA23-187b
Main duties of the job
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
About us
At Bridgewater, our PEOPLE values shape how we deliver our NHS services in your local community.
They help us deliver our mission to improve local health and promote wellbeing in the communities we serve.
After all, values are about people and they were created in partnership with our staff to reflect what they felt was important to them
Here at Bridgewater our shared values flow through the organisation.
P- Person-centred-We are passionate about individual needs and promote independence in the healthcare we provide..
E- Empowered- We empower our people and encourage new ideas to deliver and create improvements in community care.
O- Open and Honest -We behave in a way that develops relationships based on trust, openness, honesty and respect.
P- Professional-We support our people, so everyone has the right skills and training to deliver outstanding patient care.
L- Locally Lead -We are always learning about our communities and show great pride in being a local provider of health and care.
E- Efficient -We use our resources wisely to provide sustainable and value for money healthcare for our patients.
Unfortunately, we do not hold a sponsor licence for working Visas.
Job description
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.
Person Specification
Qualifications
Essential
- Relevant Clinical Professional Qualification
- Degree or equivalent clinical/advanced practice
- Extensive post registration experience
- Management/Clinical Leadership experience
- Clinical Masters Degree or working towards
- Prescribing qualification at V300 level
- Evidence of post registration/qualification
Desirable
- Specialist practitioner
Experience
Essential
- Experience of working with patients with long term conditions
- Experience of successful multi agency working including an understanding/ experience of working in a social care environment
- Evidence of influencing, motivating and negotiating with others to achieve change in relation to care
- Experience of initiating and implementing clinical care/protocols
C9835-HA23-187b
Get job alerts
Create a job alert and receive personalised job recommendations straight to your inbox.
Create alert