Job summary The role is to support both the practice staff & the Neighbourhood Team to identify and support people to reduce therisk of unplanned hospital admissions, effectively support those individualsin the community,to focus on proactively case managing people and being the preferredpoint of contact for the patient and Neighbourhood Team in order to achieve thefollowing objectives:Be a proactive member of theNeighbourhood TeamProvision of safealternatives to Secondary Care services Proactively identify vulnerable and at-risk patient groups and definesresponsive, appropriate and timely management Improvement in thequality of clinical care and outcomes for our patients Holistic andpersonalised care planning which supports people and their carer(s) to beinvolved in the planning of their care, to live well, self-manage independentlyand have systems in place to support them during crisis/exacerbation of their condition.
Integrated teamworking, as part of the delivery of Integrated Neighbourhood Teams, betweenproviders of care and support to ensure people receive the right care, at theright time, by the right people and transitions are seamless with reducedbarriers, duplication, inefficiencies and silo working.This list is not exhaustive.
Main duties of the job Main duties andresponsibilitiesTo liaisewith the registered GP & all otherproviders and services utilising, where appropriate, a multi-disciplinaryapproach.Toimplement & review individual care plans, a self-management plansContact peoplefollowing an unplanned hospital admission & those with a history of repeatadmissions,Develop & maintain a detailed knowledge of local services to enable supported signpostingof people with identified need, sharing information with the NeighbourhoodTeam.Liaisewith GPs and practice teams to identify people who are elderly, frail or whohave long term health needs & support.Identify people at risk of loss of independenceor admission to hospital as a result of inadequate social support.Implement PCSP for individual people, ensuring preventative actions aredetailed to support the appropriate use of services.Identifywhen urgent action or a step up in care is required & promptly alert therelevant member of the Neighbourhood Team, highlighting any safety concerns.Undertakevisits or telephone contact to manage people on the SNNs case load followingany unplanned hospital admissions where appropriate.Participate & in some situations, lead the Neighbourhood multi-disciplinary meetings, this includes GSF meetings,Neighbourhood MDT, Palliative Care huddles etcMaintainaccurate & up to date records of patient contactsSupportthe Primary Care Network Manager in providing KPI reports for submission as requested.This list is not exhaustive.
About us Spalding PCN comprise of 2 large practices in Spalding.
This role is based at Munro Medical Centre.We work from purpose built premises and have a small branch site in the village of Pinchbeck, we use SystmOne as our clinical system.
We employ 70+ staff and in addition to the nursing team we have a variety of other supporting clinicians and administration staff.
We are a busy practice , but we have excellent systems in place to support all clinicians in their day to day work.We have regular practice/team/clinical governance meetings and are committed to patient safety and staff wellbeing.One thing that is regularly fed-back to us from visitors/GP registrars/Locums etc is that we are a very friendly, organised and supportive team.
Job description Job responsibilities For full details regarding the role, please see the attached document.
Please note, this is not an exhaustive list.
Person Specification Experience Essential Experience of dealing with people with long term conditions Evidence of ability to work autonomously.
Evidence of working within a multidisciplinary team Qualifications Essential Registered Nurse Post graduate study in health-related studies relevant to long term conditions or equivalent experience Post registration teaching qualification or willingness to undertake Post registration qualification in non-medical prescribing or willingness to undertake as needs of service change Evidence of continuing professional development Skills and knowledge Excellent communication skills, listening, written and verbal.
Good organisational and planning skills.
Excellent prioritisation skills and ability to work to tight deadlines.
Skilled and sensitive communicator, confident in dealing with staff, people and service users Ability to deal with complex facts/situations, requiring analysis, interpretation and comparison of a range of options.
Ability to effectively organise own workload and that of others with minimum supervision Ability to achieve goals with deadlines.
Ability to work sensitively to maintain high levels of diplomacy and confidentiality Excellent knowledge of Systm1 Good working knowledge and application of Microsoft Office packages