Community Matron

To deliver nursing care in accordance with national and local policy and guidance and in accordance with the Nursing and Midwifery Council. In conjunction with GPs, practice/district nurses, social care, mental health colleagues, medicines management, ambulance services, therapists and the voluntary sector the Community Matron will lead and facilitate a patient focused, coordinated MDT and case management approach for people who are most vulnerable to and at high risk of unnecessary admission to hospital. The role will require working in partnership with individuals, carers and families and developing MDT proactive care plans to reduce risks, promote self-management and prevent the need for urgent care. The post holder will work as part of the Proactive Care Service as a highly skilled and experienced Registered Nurse to improve outcomes for local people and reduce unnecessary unplanned admission to hospital.

The post holder will be a named Community Matron for nominated GP practices but will work across the Primary Care Network area to ensure equity of access. The post holder is responsible for: proactive identification of adults at high risk of unnecessary admission to hospital who would benefit from a proactive approach to health and care needs collaborative working with adult social care, mental health, ambulance, GPs, community therapists, community nursing, geriatricians to ensure the best outcomes for individuals, families and carers supporting the implementation of work streams and improved pathways for individuals with long term conditions and complex needs using a proactive and anticipatory approach to assessment, implementation and evaluation of health and care The post holder will use an electronic patient held record system, EMIS as a record of care and all our nurses are provided with a work Iphone and Ipad for mobile working. Communication Builds and maintains strong working relationships and communicates effectively with GPs, community nursing teams, Adult Social Care, Mental Health, acute / community hospital colleagues and therapists Interprets complex information and formulates solutions to recommend on the best course of action / treatment for the individual e.g. medication reviews Responsible for ensuring effective communication with all relevant personnel pertaining to patient care and any change in treatment/management plans, part of this will include the effective use of electronic notes system, including assessment tools Responsible for establishing, communicating and maintaining effective professional relationships with community nursing colleagues, GPs and health/social care/voluntary service networks to provide a planned, co-ordinated, seamless service for individuals Maintains accurate clinical records and activity data and uses information from a wide range of sources, some of which may be conflicting, to inform clinical decision making - with due regard to confidentiality and data protection at all times Actively participates in MDTs for proactive care and risk stratification / population health management Utilises a range of effective communication skills, tools and techniques that may be complex and sensitive and that overcomes barriers to understanding Acts as an advocate for all individuals and carers to ensure a culture where needs, wishes and preferences of individuals are at the forefront of care Embraces the use of technology to support communication channels and new ways of working across care homes whilst adhering to confidentiality and information governance Attends and actively participates in weekly Primary Care Network MDTs to discuss complex cases and seeks to minimise the risk of unnecessary admission to hospital Patient Care / Safety / Quality Identifies patients at high risk of unnecessary admission to hospital and uses proactive management approach to promote wellness, early recognition of disease exacerbation, and appropriate intervention to improve patient outcomes Responsible for the effective review and prioritisation of own caseload, and the referrals, requests, and enquiries to the Community Coordination Centre when on duty as the lead clinician Works clinical pharmacists, therapists, paramedics, dietitians and others working within the Primary Care Network locality to support all aspects of proactive case management Responsible for making rapid autonomous decisions, escalating to the Clinical Lead / GP / Adult Social Care / Safeguarding as required Uses advanced clinical assessment skills, Chronic Disease Management and End of life care to support personalised, anticipatory and advanced care planning and the prevention of unnecessary admission to hospital Monitor indicators of long-term conditions, anticipating possible decline and proactively managing this to enhance well being, and maintain independence Works within the Surrey wide multi-agency safeguarding policy to ensure vulnerable adults are protected Ensures that patients and their carers expe