Mdt Nurse

Job summary TheMDT Nurse plays an important role within a PCN to proactively identify andwork with people, including the frail/elderly and those with long-termconditions, to provide co-ordination and navigation of care and support.Workclosely with GPs and practice teams to manage a caseload of patients, acting asa central point of contact to ensure appropriate support is made available topeople and their carers; supporting them to understand and manage theircondition and ensuring their changing needs are addressed.Thisis achieved by bringing together all the information about a personsidentified care and support needs and exploring options to meet these within asingle personalised care and support plan, based on what matters to the person.MDTNurses are caring, dedicated, reliable, person-focused and enjoy workingwith a wide range of people.
Have good written and verbal communication skillsand strong organisational and time management skills.
Be highly motivated andproactive with a flexible attitude, keen to work and learn as part of a teamand committed to providing people, their families and carers with high qualitysupport.TheMDT Nurse role is intended to become an integral part of the PCNsmultidisciplinary team, working alongside social prescribing link workers andhealth and wellbeing coaches to provide an all-encompassing approach topersonalised care and promoting and embedding the personalised care approachacross the PCN.
Main duties of the job Workwith people, their families and carers, to improve their understanding of theircondition.
Supportpeople to develop and review personalised care and support plans to managetheir needs and achieve better healthcare outcomes.
Helppeople to manage their needs by providing a contact to answer queries, make andmanage appointments, and ensure that people have good quality written or verbalinformation to help them make choices about their care.
Assistpeople to access self-management education courses, peer support, healthcoaching and other interventions that support them in their health andwellbeing, and increase their levels of knowledge, skills and confidence inmanaging their health.
Provideco-ordination and navigation for people and their carers across health and careservices.
Helping to ensure patients receive a joined-up service and theappropriate support from the right person at the right time.
Workcollaboratively with GPs and other primary care professionals within the PCN toproactively identify and manage a caseload, which may include patients withlong-term health conditions, and where appropriate, refer back to other healthprofessionals Supportthe co-ordination and delivery of multidisciplinary teams with the PCN.
Raiseawareness of how to identify patients who may benefit from shared decisionmaking and support PCN staff and people to be more prepared to have shareddecision-making conversations.
About us Primary care networks (PCNs) form a key building block of the NHS long-term plan.
Bringing general practices together to work at scale has been a policy priority for some years for a range of reasons, including improving the ability of practices to recruit and retain staff; to manage financial and estates pressures; to provide a wider range of services to patients and to more easily integrate with the wider health and care system.
While GP practices have been finding different ways of working together over many years for example in super-partnerships, federations, clusters and networks the NHS long-term plan and the new five-year framework for the GP contract, published in January 2019, put a more formal structure around this way of working, but without creating new statutory bodies.
Since 1 July 2019, all except a handful of GP practices in England have come together in around 1,300 geographical networks covering populations of approximately 3050,000 patients.
This size is consistent with the size of primary care homes, which exist in many places in the country, but much smaller than most GP federations.
Around 50 networks, usually in very rural areas, will cover a population of less than 30,000, but most are bigger than 50,000.
If you would like the opportunity to make a difference in our community, come and join Sutton PCN Job description Job responsibilities Applicant MUST have a car, valid Driving License & Business Car Insurance (work purpose)TheMDT Nurse plays an important role within a PCN to proactively identify andwork with people, including the frail/elderly and those with long-termconditions, to provide co-ordination and navigation of care and support acrosshealth and care services.Workclosely with GPs and practice teams to manage a caseload of patients, acting asa central point of contact to ensure appropriate support is made available topeople and their carers; supporting them to understand and manage theircondition and ensuring their changing needs are addressed.Thisis achieved by bringing together all the information about a personsidentified care and support needs and exploring options to meet these within asingle personalised care and support plan, based on what matters to the person.MDTNurses could provide time, capacity and expertise to support people inpreparing for, or following-up, clinical conversations.
Enabling them to bemore actively involved in managing their care and supporting them to makechoices that are right for them.
MDT Nurses help people improve theirquality of life.MDTNurses are caring, dedicated, reliable, person-focused and enjoy workingwith a wide range of people.
Have good written and verbal communication skillsand strong organisational and time management skills.
Be highly motivated andproactive with a flexible attitude, keen to work and learn as part of a teamand committed to providing people, their families and carers with high qualitysupport.TheMDT Nurses role is intended to become an integral part of the PCNsmultidisciplinary team, working alongside social prescribing link workers andhealth and wellbeing coaches to provide an all-encompassing approach topersonalised care and promoting and embedding the personalised care approachacross the PCN.
Key ResponsibilitiesWorkwith people, their families and carers, to improve their understanding of theircondition.Supportpeople to develop and review personalised care and support plans to managetheir needs and achieve better healthcare outcomes.
Helppeople to manage their needs by providing a contact to answer queries, make andmanage appointments, and ensure that people have good quality written or verbalinformation to help them make choices about their care.
Assistpeople to access self-management education courses, peer support, healthcoaching and other interventions that support them in their health andwellbeing, and increase their levels of knowledge, skills and confidence inmanaging their health.Provideco-ordination and navigation for people and their carers across health and careservices.
Helping to ensure patients receive a joined-up service and theappropriate support from the right person at the right time.Workcollaboratively with GPs and other primary care professionals within the PCN toproactively identify and manage a caseload, which may include patients withlong-term health conditions, and where appropriate, refer back to other healthprofessionalsSupportthe co-ordination and delivery of multidisciplinary teams with the PCN.Raiseawareness of how to identify patients who may benefit from shared decisionmaking and support PCN staff and people to be more prepared to have shareddecision-making conversations.Exploreand assist people to access a personal health budget where appropriate.Workwith people, their families, carers and healthcare team members to encourageeffective help-seeking behaviors.SupportPCNs in developing communication channels between GPs, people and theirfamilies and carers and other agencies.
Identifycarers and help them access services to support them.Mayrequire conduct follow-ups on communications from out of hospital andin-patient services.
Maintainrecords of referrals and interventions to enable monitoring and evaluation ofthe service.Supportpractices to keep care records up-to-date by identifying and updating missingor out-of-date information about the persons circumstances.Contributeto risk and impact assessments, monitoring and evaluations of the service.Work withcommissioners, integrated locality teams and other agencies to support andfurther develop the role.Core Tasks and Functions1.Enable access topersonalised care and supporta.
Take referrals orproactively identify people who could benefit from support through careco-ordination.b.
Have a positive,empathetic and responsive conversations with people and their families andcarer(s), about their needs.c.
Increasing patientsunderstanding of how to manage and improve health and wellbeing by offeringadvice and guidance.d.
Develop an in-depthknowledge of the local health and care infrastructure and know how and when toenable people to access support and services that are right for them.e.
Use tools to measurepeoples levels of knowledge, skills and confidence in managing their healthand tailor support to them accordingly.
f.Supportpeople to develop and implement personalised care and support plans.g.
Review and updatepersonalised care and support plans at regular intervals.
h. Ensure personalisedcare and support plans are communicated to the GP and any other professionalsinvolved in the persons care and uploaded to the relevant online care records,with activity recorded using the relevant SNOMED codes.
i.Wherea personal health budget is an option, work with the person and the local ICSteam to provide advice and support as appropriate.2.Co-ordinate andintegrate carea.
Make and manageappointments for patients, related to primary, secondary, community, localauthority, statutory, and voluntary organisations.b.
Help peopletransition seamlessly between secondary and community care services, conductingfollow-up appointments, and supporting people to navigate through the widerhealth and care system.c.
Refer onwards tosocial prescribing link workers and health and wellbeing coaches where requiredand to clinical colleagues where there is an unaddressed clinical need.d.
Regularly liaisewith the range of multidisciplinary professionals and colleagues involved inthe persons care, facilitating a co-ordinated approach and ensuring everyoneis kept up to date so that any issues or concerns can be appropriatelyaddressed and supported.e.
Actively participatein multidisciplinary team meetings in the PCN.f.Identifywhen action or additional support is needed, alerting a named clinical contactin addition to relevant professionals, and highlighting any safety concerns.
g. Record whatinterventions are used to support people, and how people are developing ontheir health and care journey.Keepaccurate and up-to-date records of contacts, appropriately using GP and otherrecords systems relevant to the role, adhering to information governance anddata protection legislation.Worksensitively with people, their families and carers to capture key information,while tracking of the impact of care co-ordination on their health and wellbeing.Encourage people, their families and carers to provide feedback and to share theirstories about the impact of care co-ordination on their lives.Recordand collate information according to agreed protocols and contribute toevaluation reports required for the monitoring and quality improvement of theservice.Establishstrong working relationships with GPs and practice teams and workcollaboratively with other care co-ordinators, social prescribing link workersand health and wellbeing coaches, supporting each other, respecting eachothers views and meeting regularly as a team.Demonstratea flexible attitude and be prepared to carry out other duties as may bereasonably required from time to time within the general characterAbility to travel across Home Visiting sites and avalid UK driving licence for roles where postholders are required to drive aspart of their role.Applicant MUST have a car, valid Driving License & Business Car Insurance (work purpose) Person Specification Qualifications Essential *Current NMC Registration- RGN *Membership of a professional body ( RCN) * Ability to work autonomously * Ability to work effectively with other members of the team and other partners and agencies * Commitment to on-going personal and professional development Desirable *Nursing Degree Qualification BSC or MSC or working towards *Change management skills and experience of leading a team initiative or change * Motivational interviewing * Worked within teaching/training environment * Ability to be self -directed and motivated * Innovative Experience Essential -Experience relevant to particular post -To have an understanding of current issues affecting the NHS -A sound understanding of national and local health agenda - Awareness of the legal and ethical issues of the role - Excellent interpersonal and communication skills - Ability to work effectively in a multi disciplinary team as a key player - Knowledge of needs of patients with long-term conditions - Aware of accountability of own and other roles - Knowledge of health promotion strategies - Knowledge of patient group directions and associated policy Desirable * Previous Health /Social experience.
* Willingness to participate in clinical supervision and performance review * Willingness to undertake training at a higher level if necessary * Work within a multicultural environment * Awareness of clinical governance in primary care Skills & Abilities Essential Ability to provide quality care that is responsive to patients needs and to work in partnership with patients and clients and other agencies.
Good written and verbal communication Good interpersonal skills Ability to organise own time effectively Ability to work effectively as part of a team, valuing contributions from team members Ability to work independently following spoken or written instructions Desirable IT experience / computer skills Other Essential Reliable Flexible Willingness to learn new skills Adapt positively to changes in working practices and patterns.
Ability to travel across Home Visiting sites and a valid UK driving licence for roles where postholders are required to drive as part of their role.