Community Matron

**See uploaded document for full details**: Main duties To provide expert clinical case management for people with frailty who may have multiple long-term conditions and are at risk of deteriorating health that may result in declining clinical quality of life or avoidable hospital admission or unnecessary length of hospital stay. Supporting and working with close family, carers and wider family members Develop relationships with staff within the practices, ICT, Older Peoples Mental Health service, Rapid Response and adult social care collaborating with them on a day-to-day basis. Undertake comprehensive assessment of the physical and psycho-social care needs of people with frailty who may also have complex chronic disease. This will involve using a single assessment process, gathering and interpreting information, carrying out and ordering investigations and analysing the results alongside and with the support of GP colleagues.

Establish an individuals functional capabilities with regard to frailty as well as any long term conditions clinical management. Develop a person led evidence-based holistic health and social care plan in conjunction with medical and other health and social care colleagues. Develop person led care plans in partnership with patients and their relatives. Work collaboratively with colleagues and use the eFI/Rookwood frailty scoring system to actively seek out patients who will benefit from clinical case management techniques to avoid unplanned hospital admission and reduce the length of hospital stays.

Prioritise individuals for assessment and management according to their health status and needs, referring for specialist assessment, diagnostic tests and programmes of support as appropriate. Authorise and facilitate the case managed persons discharge from hospital by co-ordinating care and services to be delivered within primary care, working in partnership with hospital ward staff, the integrated care team and other appropriate agencies, including the voluntary sector. Establish and maintain excellent communication with individuals and groups, exploring complex issues relating to care options and decisions and sustain effective working relationships across all health and social care service organisations. Use a high level of communication and interpersonal skills to communicate effectively with patients and carers, in particular the skills needed for cognitive assessment and mental health status.

Refer individuals to mental health and/or other services where appropriate. Enable individuals to access psychological support. Ensure patients needing palliative care or End of Life Care receive high quality care aligned to the Gloucestershire End of Life Strategy and NICE Clinical Guidelines. Challenge prejudice and inequalities in access to mainstream provision for individuals with frailty and may have long term conditions.

Establish effective working relationships with people, their families and carers. This will include promoting individual rights and recognising and respecting their ability to co-produce care plans and associated delivery. Interpret and discuss assessment outcomes with people, carers, their GPs and other health and social care professions and the voluntary sector. Work with people and carers to inform and educate about the early warning signs in order to facilitate rapid management of complications or crises.

Enable people to be as independent as possible by facilitating a range of self-management strategies through undertaking desired occupations and non
- occupational activities including the support that is available from the voluntary sector. Utilise knowledge and experience of Expert Patient Programmes and Self-Management Programmes to enhance both an individuals care pathway and the quality of service provided. Monitor quality and effectiveness of clinical care for people with frailty through audit and research. Contribute to the audit process in relation to user expectations, appropriateness and effectiveness of the service and continuous improvement.

Work effectively with Practices, local health, social care, housing and voluntary sector services. Collaborate with service providers, people and carers to develop and review integrated patient pathways. Challenge existing knowledge, current poor practice and be open to be challenged by others. Constantly strive to identify training needs for self and others.

Accept responsibility for teaching professional colleagues, nursing auxiliaries, student nurses, people and carers. To fulfil the requirements for maintaining a professional registration. The post holder is expected to adhere to local policy and procedures. To work flexibly over a 7 day working week as part of a planned rota if required.