Community Matron

The post holder will be required to provide clinical case management to a group of patients who meet the Trust identified criteria, who have long term conditions and other complex medical and social problems. They will develop the clinical case management role and function across health and social care organisations. The primary function of the role is to maximise the patients health, clinically assess and treat patients in a defined group and reduce risks that contribute to ill health, thereby reducing unnecessary admissions to acute services, reducing demand on GP time and facilitating the delivery of efficient, effective, co-ordinated and timely high-quality care to patients. Duties and Responsibilities Clinical Matron 1.

Maximise independence by supporting people with long term conditions and highly complex needs to remain in their own homes as appropriate, by utilising and commissioning available resources. 2. Undertake clinical assessment and provide treatment for patients within the defined group. 3.

Link with existing services to facilitate early discharge from hospital and prevent re-admission. 4. Develop Partnerships and joint working within the local health and social care economy. 5.

Work collaboratively across organisation boundaries to support the effective and co-ordinated provision of social care and health care services. Clinical Requirements: 6. Conduct a comprehensive health and social care assessment, utilising any current information in order to develop an individualised plan of care for patients within a defined group. This will include: Review of health assessment including medical history Physical examination Assessment and review of medication Prescribing in conjunction with management plans Making referrals for diagnostic tests Functional /cognitive assessment Assessment of social care needs.

7. Develop, monitor, and manage the plan of care in collaboration with the primary health and social care team and others through: Application of clinical knowledge about long term conditions Analysis of symptoms and data Identification of risk factors associated with exacerbation of patients condition Recognition of early signs and symptoms of acute illness. Involving patients and carers in the development of the care plan and ensuring that their views and abilities are reflected. Documentation of progress and continuous reassessment Referral and investigation.

8. Set up and actively participates in case review to evaluate the outcomes of care plans including social care needs. 9. Co-ordinate care and treatment to avoid fragmentation, duplication, and delay in the least intensive setting appropriate to the patients needs by: Prioritisation and co-ordination of multiple health and social care needs Referrals to specialist services Ensuring effective communication and sharing of appropriate information amongst professionals to avoid conflicting treatments.

Integration across health and social care (inc. voluntary sector and housing) Identifying deficiencies in service provision and addressing these as appropriate (ie through commissioning services for individuals) Understanding and working through entitlements to social care and necessary financial assessments. 10. Be aware of and adhere to, the Professional bodies Standards for administration of Medicines Act 1992, and the Misuse of Drugs Act 1971.

Leadership Requirements 11. Lead the process of identifying their caseload through interpretation of the information available on the health needs of the locality in which they are based and contribute to the collection of data to monitor outcomes measures for the caseload 12. Participate in the development of case management across the Trust. 13.

Provide clinical leadership and mentoring to those staff developing into a case management role. 14. Make, implement, and communicate changes to clinical practice as necessary in relation to case management. 15.

Challenge professional and organisational boundaries to ensure that the Case Management role is focused on meeting the needs of service users, thus promoting continuity of high-quality patient centred health and social care. 16. Acts as an advocate and champion for patients in a variety of forums and professional groups and challenges attitudes and behaviour. 17.

Act as a role model so that patients receive the most effective care possible through: Encouraging optimum management of long-term conditions to ensure that the patient is functioning at the most independent level possible Acting in patients interests at all times. 18. Contributing to the development of policy and services to reflect the needs of the patient caseload. MANAGERIAL RESPONSIBILITIES 19.

Manage the complex clinical and social care interventions of individuals within an identified patient group on an ongoing basis. 20. Undertake risk assessment in relation to individuals within the client group. 21.

Monitor and respond to the development of changing clinical and soci