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Detailed job description and main responsibilities

To be responsible for planning, reviewing and renegotiating programmes of care to promote health gains and maximise independence within a defined caseload in conjunction with the Integrated Care Teams (ICT) and Care Home Advanced Model of Provision (CHAMP).

Develop and maintain communication with people about complex issues and/or in difficult situations.

To use advanced skills and expert knowledge to access the physical and psycho-social needs when there are complex and/or undifferentiated abnormalities, diseases and disorders of a defined client group, instigating therapeutic treatments based on best available evidence in order to improve health outcomes.

To play a lead role in integrated community care teams (ICT) to improve holistic assessment and approach to health and social care needs of patients.

To play a lead role in improving the access to health care within care home settings.

To be professionally and legally responsible and accountable for all aspects of own work, including the management of patients in your care.

To accept clinical responsibility for a diverse and often complex caseload of patients, to organise this efficiently and effectively with regards to clinical priorities and use of time.

Demonstrates advanced listening, communication and negotiation skills to understand what matters to each individual patient, to ensure the patient is at the centre of all decisions and to agree and work towards appropriate goals for every patient

To work closely with medical, nursing, allied health professional and volunteer services across primary care, secondary care and community settings to ensure patients receive appropriate investigation, intervention and care planning to ensure their physical and mental health is optimally and safely managed to afford them the best possible for basis for rehabilitation, reablement and recovery.

To develop / maintain advanced specialist clinical skills and knowledge to identify changes in a patient’s condition through clinical examination.

To undertake interventions consistent with evidence-based practice, transferring and applying knowledge and skills to meet client needs.

To use the skills and knowledge to make referrals for diagnostic tests.

To evaluate the effectiveness of interventions in meeting prior agreed goals and making any necessary modifications.

As a non-medical prescriber (NMP) take necessary assessments, medicines review and prescribe within the Prescribing Framework.

As a supplementary prescriber, actively manage the polypharmacy and other medication issues associated with chronic disease management and care home residents in conjunction with the patient’s medical practitioner, through the use of clinical management plans.

To be responsible for ensuring the provision of planned intervention in all aspects of chronic disease management with appropriate input from the multidisciplinary team in order to reduce the risk of complications and deterioration of the patient’s condition.

To improve the patients “self-management” of their condition wherever possible taking into account the functional and cognitive patient assessment.

Ensures that the care provided and services delivered are in line with local and national guidelines and policy

Maintaining accurate and legible patient notes in accordance with Trust and national professional policies and guidelines.

Use advanced clinical skills and expert knowledge to provide proactive monitoring and provide timely intervention.

To work as an integral part of the integrated community nursing, multidisciplinary and multiagency teams.

To actively participate in projects designed to improve the proactive management of patients

Make operational judgements.

Develop own skills and knowledge and contribute to the development if others within the guidelines of the NMC Code of Conduct.

Identifying clearly the wider benefits that developing knowledge, ideas and work practice will bring

Challenging tradition and take risks, accepting joint responsibility for any arising problems and tensions and using these to inform future practice

To work independently managing own caseload in conjunction with the General Practitioner, Community Consultant Geriatrician, Social workers, Medicines Management, Mental Health teams, Learning disability teams, Integrated nursing teams, AHPs and secondary care teams as appropriate.

Demonstrates professional responsibility for adherence to Trust and NMC policies and procedures.

To work directly with multi-professional teams to assist in the management of risk, facilitation of complex case reviews and the immediate crisis management.

The post holder may be exposed to frequent distressing or emotional circumstances with patients who are terminally ill or suffering end of life events, and will be required to deal with this situation in a professional manner.��

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Please refer to Job Description attached for full list of duties and responsibilities.