1 year fixed term contract (Maternity leave cover). Secondment supported.

We have an exciting opportunity for a nurse or physiotherapist with previous experience managing respiratory patients, either in the acute or community setting, to join the innovative COPD team for 1 year.

The team comprises of a mixture of matrons, physiotherapists, a dietitian, a clinical psychologist, administrative support and therapy assistants. Clinical leadership is provided by a respiratory consultant from the LGT.

The COPD team delivers a wide range of services including:

• An SOS admission avoidance and early supported discharge services
• Annual review service
• COPD diagnostic service
• Pulmonary rehabilitation (PR)
• Self management education days enabling the patients to manage their disease in a much more proactive way.
• Home oxygen assessment and review service

The successful candidate will be a registered nurse/physiotherapist with the relevant experience who will support the team to manage their own COPD patient caseload. They must be comfortable and confident to work alone and within the large team.

The SOS service delivers care Mon- Sun service, 9-5pm and is managed by 2 clinicians per day, except the weekends, where 1 person is rostered on. A day off in the week is allocated for a weekend worked.

Computer literacy and the ability to use an iPad for remote working is essential.

Please note that Oxleas operates a probationary period, further information is available on request.

Main duties of the job

The post holder will proactively manage a caseload of patients requiring complex case management in order to prevent hospital admissions and improve patient health outcomes.

Working autonomously, the post holder will have continuing responsibility for proactively monitoring and managing, patients on the caseload. The post holder will be expected to possess skills in advanced clinical assessment, diagnostic reasoning and using these skills will assist in the recognition of early symptoms of disease exacerbation.

The post holder will be expected to be a competent leader and case manager and critical thinker navigating the patient through the COPD care pathway which spans across the primary, secondary care interface. Pivotal to the care pathway is the prevention of unnecessary admissions and facilitation of early supported discharge to reduce lengths of stay.

The post holder will be expected to work according to their shift allocation as organised on health roster every 3 months.

About us

Oxleas - About Us

Oxleas offers a wide range of NHS healthcare services to people in community and secure environment settings. Our services include community health care such as district nursing and speech and language therapy, care for people with learning disabilities and mental health care such as psychiatry, nursing and therapies. Our multidisciplinary teams look after people of all ages and we work in close partnership with other parts of the NHS, local councils and the voluntary sector and through our new provider collaboratives. Our 4,300 members of staff work in many different settings including hospitals, clinics, prisons, secure hospitals, children's centres, schools and people's homes.

We have over 125 sites in a variety of locations in the South of England. In London we operate within the Boroughs of Bexley, Bromley Greenwich and into Kent. We manage hospital sites including Queen Mary's Hospital, Sidcup and Memorial Hospital, Woolwich, as well as the Bracton Centre, our medium secure unit for people with mental health needs. We are the largest NHS provider of prison health services providing healthcare to prisons within Devon, Dorset, Bristol, Wiltshire and Gloucestershire, Kent and South London. We are proud of the care we provide and our people.

Our purpose is to improve lives by providing the best possible care to our patients and their families. This is strengthened by our new values:

• We're Kind
• We're Fair
• We Listen
• We Care

Job description

Job responsibilities

The COPD Community Matron / case manager will be expected to achieve the competencies set nationally by Skills for Health 2005 (www.skillsforhealth.org.uk). These can be summarised as follows

• To be responsible and accountable for providing expert care to COPD patients who are registered with a Greenwich GP
• Utilisation of advanced clinical skills and expert knowledge to plan, implement, monitor and review individualised patient-directed programmes of care to patients with COPD including health promotion interventions.
• To undertake goal centred interventions that are evidence-based, evaluating the effectiveness of these at regular intervals with a view to improving care continuously.
• Develop risk management plans that will enable individuals to remain safely within their homes
• Use expert knowledge and skills as a non medical prescriber to manage patient medication within own areas of competency, developing clinical management plans in partnership with GP colleagues where necessary.
• Anticipate individual care needs and develop appropriate care plans, involving carers and relatives
• To provide individuals and their carers with the necessary education that will enable them to plan for unavoidable disease progression and self manage as far as possible.
• To work collaboratively with members of the multi professional team to ensure that the patients needs are met, making appropriate referrals are made where necessary.
• Develop practices which promote patient choice and well-being
• To be responsible for ordering stock and other resources when asked
• Ensure that the needs of individuals who are vulnerable are highlighted and addressed in a timely manner
• To be a competent clinical leader demonstrating a willingness to work as an integral part of a multi professional team
• Be a highly skilled communicator, written and verbal, with a capability for communicating within a variety of professional groups, challenging attitudes where necessary
• To manage a caseload of patients with COPD (Specialist community matron/case manager)
• To practice at an advanced level demonstrating an in-depth knowledge of all aspects of the management of COPD that is evidence-based
• To undertake advanced physical and social assessments and examinations, and initiate appropriate diagnostic activity and treatment
• To work with other community matrons/case managers to ensure a consistency of approach to patient care and to support clinical supervision arrangements within the Trust
• To work collaboratively with other specialist and multidisciplinary teams, such as GPs, District Nurses, Consultants
• To support the and COPD self management programmes such as GRACE and pulmonary rehabilitation
• To contribute towards reducing frequent admissions and bed days of patients with COPD
• To help improve the diagnostic rate of COPD in primary care supporting the delivery of an ARTP accredited quality assured spirometry clinic.
• To work alongside the clinical lead in the new/confirmed diagnosis of COPD in producing treatment plans including self-management and education at consultant lead MDT sessions
• To participate in the delivery of education sessions on the Greenwich Respiratory Advice and self-Care Education (GRACE) programme in a community
• To be confident in the delivery of educational topics including: pathophysiology of COPD, COPD medications, managing exacerbations, breathlessness, productive cough, anxiety and low mood and the importance of exercise and a balanced diet
• To participate in the delivery of pulmonary rehabilitation with the support of the pulmonary rehabilitation lead
• To participate in disease specific audit and data collection
• To act in accordance with the clinical governance framework within the Trust
• To share knowledge and skills with patients and families as a key therapeutic intervention and to enable self care and autonomy
• To identify the educational requirements of primary and social care colleagues in relation to the management of COPD and lead on meeting these needs
• To participate in clinical supervision, appraisal and personal development programme
• Ensure own professional development and clinical skills through attending courses, workshops and conferences and applying the knowledge gained in clinical practice
• To interface with primary and secondary care teams to enable the implementation of managed care pathways in line with local and national guidance
• To advise on and develop new initiatives and ways of working informed by local and national policy
• To be involved in the development of guidelines, policies and protocols within the Trust
• To promote effective collaborative working relationships with health and social care colleagues and those within support networks and the voluntary sector
• To act as a change agent and innovator, planning, instigating and evaluating changes
• To proactively demonstrate the positive impact of case management on the reduction of avoidable admissions and lengths of hospital stay
• Contribute to the service development within the Trust in line with national strategies particularly the COPD
• To maintain accurate and legible and timely records
• To act as leader, mentor and preceptor to staff within the Trust

Person Specification

degree/diploma

Essential

• degree/diploma in nursing/physio

Desirable

• post grad modules in respiratory

Experience

Essential

• 4 years experience

Desirable

• community experience
• delivery of self management

communication skills

Essential

• demonstrate varied communication skills

car driver and user

Essential

• access to care

Employer details

Employer name

Oxleas NHS Foundation Trust

Address

151 Goldie Leigh Hospital

Lodge Hill

Greenwich

SE2 0AS

Any attachments will be accessible after you click to apply.

277-6593745-CPH