The post holder will be a key member of the Integrated Neighbourhood Teams, in which you will case manage complex patientand be responsible for the smooth operation of co-ordinating complex multi-disciplinary team meetings and working as an autonomous practitioner within their specialty area.

The post holder will be the link between primary care and key core provider services within the locality. You will be working with General Practitioners, Practice staff, Community services from ELHT, Advanced Nurse Practitioner(s) (where in post), specialist services and partner professionals and agencies from within and beyond the INT to build high impact partnerships and drive transformation.

You will be developing and promote a case management approach to care and promoting the benefits of co-ordinated, holistic care for patients and facilitating this process through the facilitation, organisation and planning of multi-disciplinary team meetings. You will need to be appropriately trained to understand holistic care planning and delivery to advise INT members and colleagues to deliver a quality patient centred service.

Main duties of the job

The post holder provides a case management approach for patient with complex need in the community, within the Integrated Neighbourhood team. The post holder will work in the community assessing patients in the own environments, to provide the best possible patient outcomes. They will ensure collaborative working across divisions, with General Practitioners, partner professionals and agencies to secure care closer to home and positive outcomes for patients and their families.

The post holder will provide the leadership, direction, and line management necessary for effective and efficient service delivery and will support the Manger in the delivery of strategic and organisational initiatives and priorities, and reducing avoidable bed days/admissions, whilst maintaining high standards of clinical practice and professional conduct.

Car driver with access to a vehicle is essential

Please refer to job description for full details.

About us

Established in 2003, East Lancashire Hospitals NHS Trust (ELHT) is a large integrated health care organisation providing high quality acute and community healthcare for the people of East Lancashire and Blackburn with Darwen.

The organisation puts safety and quality at the heart of everything we do, invests in and develops its workforce, works with key stakeholders to develop effective partnerships and encourages innovation and pathway reform to deliver best practice.

We employ over 8,000 staff, many of whom are internationally renowned and have won awards for their work and achievements.

The District Nursing Service provides a supportive environment and provides staff with many professional development opportunities

Job description

Job responsibilities

Work within the model of the INT, providing leadership and support on the matters relating to admission avoidance and the transfer of care.

Work closely with all services integrating working practices to streamline processes, share knowledge and benefit patient experience, outcomes and flow.

Contribute to the development and provision of a responsive and proactive neighbourhood locality based approach to the prevention of avoidable hospital admissions through the support and mentoring of the CCMs and INT to identify and mobilise interventions to reduce risk and maintain patients in their own home environment where this is possible.

Act as a resource and first point of contact for the Complex case Managers, to improve communication and consistency of care for patients receiving a number of different services and or requiring additional support to minimise risk of admission as identified by risk profiling, case finding and local intelligence.

Ensure the coordination, planning and delivery of regular multi disciplinary team meetings happens.

Chair complex multidisciplinary meetings, ensuring all documentation is recorded regarding outcomes, facilitate the process of agreeing a case manager and case management approach.

Support case managers in setting up of meetings and liaising with appropriate services and the patient and carers where relevant.

To utilise clinical expertise to facilitate care closer to home and promoting a holistic, multi agency response to case management to meet the patients needs.

Engage proactively with key stakeholders (including for example General Practitioners, Advanced Practitioners, the Integrated Neighbourhood Teams, specialist services, Social Services, independent/ private sector providers, and ICAT/ IHSS from within and beyond the organisation to identify patients who require supportive intervention and case management to prevent avoidable hospital admission and enable those individuals to remain in their own home environment.

To follow the progress of those patients identified on case management registers from the localities who are admitted to acute care and support an early transfer home once the patients condition has stabilised, liaising with case managers and members of the integrated team and key partners to reduce the risks associated with transfer of care,

To assess, receive and review data regarding patients who regularly attend/ are admitted to acute care, liaising with patients and relatives/ carers as appropriate the integrated neighbourhood team and key stakeholders to develop a holistic case management approach to support individuals to remain independent and prevent avoidable readmission.

To be involved with and support the development and on going maintenance of data management systems.

Contribute to the development and implementation of systems and processes that ensure the needs of disadvantaged groups are identified and progressed for example the homeless and travelling families.

Contribute and/or lead training and/or development activities within and beyond the Division to raise awareness of community provision, capacity and capability.

Actively promote a focus on self-care/management to reduce reliance on services and increase levels of independence within the patient population.

Work in collaboration with the integrated neighbourhood team to provide information, prepare patients and their families/ carers for changes in the patients condition and actively encourage and support decision making and choice for end of life care including the use of fast track and CHC processes.

Prioritise and manage own workload to ensure responsive care/interventions by staff with the level of skill and competence to meet patient need and provide advice and support to team members regarding the care/ management plan.

Responsibility for the workload of the Complex Case Manager Support to ensure the smooth running of the MDT meetings occurs and meets planned objectives.

Ensure own leadership style facilitates effective communication, collaboration and motivation of staff and partners to promote an integrated and holistic approach to the management of future care for patients and carers.

Person Specification

Person spec

Essential

• RGN/ RMN/ HCPC registered therapist/ social worker
• Evidence of recent professional development
• Post registration experience, usually 12 months
• Understanding of a case management approach
• Ability to demonstrate evidence of working holistically to deliver person centred care
• Understanding of self management and self care principles
• Community care legislation. Health and Social Care policy including Mental Capacity. Current developments in Integrated Neighborhood team developments.
• Up to date clinical knowledge. Including long term conditions management and integration Evidence based practice

Desirable

• Leadership qualifications
• Management Qualifications
• 12 months recent community experience or 12 months rehabilitation experience.
• Experience of being a case manager
• Knowledge of health promotion/education/hospital avoidance.

Employer details

Employer name

East Lancashire Hospitals NHS Trust

Address

Daisyfield Mill

Appleby Street

Blackburn

BB1 3BL

Any attachments will be accessible after you click to apply.

435-CIC-117-24