Job summary Are you a Registered Nurse with an interest in caring for people livingwith long term conditions and increasing frailty, to support them to remainliving independently at home or a residential care setting, ensuring planned,optimised and co-ordinated health care for them and their families.Poole Central Primary Care Network, provides services on behalf of fiveGP Practices to the population of central Poole town, Hamworthy, Upton and Lytchett.We are looking to recruit a registered Nurse to our Enhanced Care Team,ideally with previous experience in a community or primary care setting whowould like to join our multi-professional Enhanced Care Team, providing both onthe day urgent support and proactive planned care and long-term conditionsmanagement.As anexperienced RGN, the role will be to co-ordinatethe clinical case management for frail and complex health patients, who are atrisk of further deterioration in health, an avoidable hospital admission orunnecessary length of hospital stay.This role is offered on a part-time/full-time basis and open to a flexible working pattern.
Main duties of the job To work as a member of the Poole CentralPrimary Care Network Enhanced Care Team to co-ordinate clinical case managementfor frail and complex patients and those with long term conditions who are atrisk of further deterioration in health or an avoidable hospital admission orunnecessary length of hospital stay.
To be responsible for a case-load of patientswho have either been identified using an agreed case finding tool (ElectronicFrailty Index or Rockwood) or whom have been identified by another healthcareprofessional as frail or as having a long-term condition.
As part of a team approach, to be responsiblefor identifying an individuals principle needs through a holistic,comprehensive assessment, develop care plans and work closely with othermembers of the MDT and primary care/community care team to support patients inthe community.
To support preventativecare, screening and patient education to enable the patient to manage frailtyand long-term condition.To be adaptable and able to work across allaspects of the service, including where needed, supporting the Care Home andAcute home visiting services.
About us PooleCentral PCN is the second largest PCN in Dorset and one of the first to developan operational Hub with a central co-ordination team and clinical teamsco-located in a dedicated building.The PCNservices comprise a multi-professional Enhanced Care Team, responding to theneeds of the population who are housebound or living in long term residentialcare.
The ECT comprises ANPs, RNs, HCAs, Paramedics, Specialist Diabetes andRespiratory Nurses and Clinical Pharmacists, working together to optimise clinicaloutcomes and support people to remain living independently whenever possibleand working closely with Practice Teams to ensure effective co-ordinated care.We workcollaboratively with partners in health and social care and are currentlydeveloping a number of pathways that involve models if integrated working andinformation systems and digital technology have a key part to play in achievinggreater efficiency in how we work.Thepost-holder will be employed through The Adam Practice (Lead Practice) onbehalf of the PCN and details of Terms and Conditions of employment areavailable on request.
Job description Job responsibilities To undertake a holistic fullassessment of the physical and psycho-social care needs of complex and frailpatients and those with long term conditions, involving carers and relatives.
To establish an individuals functional capabilities with regards tofrailty, as well as ability to manage other long-term health conditions.
To provide cognitive assessmentand identification of mental health needs, referring as appropriate.
To identify an individuals principle needs and support them in thedevelopment of plans to address related issues, supporting self-managementwhere feasible.To develop a person centred,evidence-based holistic health and social care plan in conjunction withmedical/other health professionals and social care colleagues.
To provide co-ordination of clinical case management for complex andfrail patients and those with long term conditions, who are at risk ofdeclining clinical quality of life or avoidable hospital admission.
To discuss assessment outcomes with patients, carers, their GPs andother health and social care professionals.
To liaise closely with other health and social care professionals toprovide community care and support to meet the needs of an individual.To identify social isolation andloneliness, being proactive in sign-posting to relevant resources to empowerpatients to remain active and engaged within their communities.
Work closelywith the social prescribing team.Using a high level of communication and interpersonal skills,establish effective working relationships with patients, their families andcarers.To recognise and identify adeterioration in an individuals health and act promptly to reduce risk ofrapid deterioration or where appropriate avoid hospital admission.
Refer ontorelevant health professional as required.To educate individuals andcarers/relatives to identify early warnings of deterioration in order tofacilitate rapid management of complication or crises.To facilitate early discharge, wherepossible, from hospital for case managed patients by co-ordination of care andservices to be delivered within primary care/community.
To identify those individuals with more complex health needs andrefer for an holistic, multi-dimensional, interdisciplinary assessment withmembers of the MDT specialising in older peoples health and/or specialising inlong term conditions, to include appropriate specialist secondary careexpertise.
To participate in the MDTmeetings, where appropriate identify patients that may require an MDT review.
Person Specification Qualifications Essential Registered Nurse Desirable Mentorship Qualification Post Graduate qualification Experience Essential Previous experience working in primary/community care setting or working in a relevant secondary care role ie.
Care of the Elderly Experience of working under own direction Ability to self-motivate, organise and prioritise workload Desirable Experience of supporting service improvement Experience at supporting peers, new learners and mentoring junior colleagues Personal Qualities and Attributes Essential Excellent written skills and a high level of verbal communication skills Demonstrates compassion and understanding of holistic, patient centred care Ability to use own initiative and recognises own scope limitations Demonstrates team player qualities Information Technology Essential Evidence of working with IT systems including Word, Access, Excel Ability to handle sensitive information confidentially, full awareness of data security Other Essential Subject to the provisions of the Equality Act, able to travel using own vehicle on Network business