Community Matron

To assess and provide advanced level interventions for patients with long term conditions to achieve quality of life and independence where possible. To work within the integrated team and case managers to facilitate early discharge from hospital To work within the integrated team and case managers to prevent unnecessary admission to hospital To work with all health care professionals, and statutory/non statutory agencies to provide a seamless, integrated service to our service users. To provide a weekend on-call telephone support service between 8am and 5pm. To facilitate and develop a service providing complex case management.

To proactively case find patients who are very high intensity users of primary and secondary healthcare and / or are at high risk of unplanned admission to hospital. To educate and support the members of the multi-disciplinary teams to intensively case manage these patients. To intensively case manage their own caseload of patients with highly complex and unstable health needs. Develop systems and processes to support intensive case management within the multi-disciplinary team and with partners across the health system.

work with and refer appropriately to other agencies to enable identified patients to be intensively managed in a pro-active way with the aim of preventing hospital admission, supporting early discharge and reduce GP contact. Be accountable for the intensive case management and where appropriate intervention of a defined patient caseload. Case finding to actively work with GPs and other agencies, and with appropriate information technology, such as PARR ++, to case find patients. Be a champion for people with long term conditions.

The post holder will practise as a non-medical prescriber in accordance with the Trusts non-medical prescribing policy, protocols, national policies, and within ones scope of competency.