Clinical Care Specialist

Job Summary

This exciting role will provide a high-quality service to housebound patients on behalf of their registered GP Practice, and the wider PCN.

You will be an experienced clinician who will be acting within their professional boundaries and competencies. You will provide care for the presenting patient from initial history taking, clinical assessment, diagnosis, treatment, referral (where required), evaluation, and follow-up of care.

Main Duties of the Job

This role will involve clinically examining and assessing patient needs from a physiological and psychological perspective and planning clinical care accordingly.

You will assess, diagnose, plan, implement, and evaluate interventions/treatments for patients with complex needs. Proactively identify, diagnose, and manage treatment plans for patients at risk of developing a long-term condition (as appropriate).

You will refer patients for investigation or specialist opinion, where appropriate. Diagnose and manage both acute and chronic conditions, integrating both drug and non-drug-based treatment methods into a management plan.

You will work with patients to support compliance with and adherence to prescribed treatments. Ensure provision of continuity of care, including follow-up appropriately.

You will take guidance and instruction from the registered GP, when and if required.

Key Responsibilities:

• Clinically examine and assess patient needs from a physiological and psychological perspective and plan clinical care accordingly.
• Assess, diagnose, plan, implement, and evaluate interventions/treatments for patients with complex needs.
• Refer patients for investigation or specialist opinion, where appropriate.
• Diagnose and manage both acute and chronic conditions, integrating both drug and non-drug-based treatment methods into a management plan.
• Work with patients to support compliance with and adherence to prescribed treatments.
• Ensure provision of continuity of care, including follow-up appropriately.
• Take guidance and instruction from the registered GP, when and if required.
• Where the post holder is an independent prescriber: to prescribe safe, effective, and appropriate medication as defined by current legislative framework.
• Provide information and advice on prescribed or over-the-counter medication on medication regimes, side effects, and interactions.
• Prioritize health problems and intervene appropriately to assist the patient in complex, urgent, or emergency situations, including initiation of effective emergency care.
• Refer patients to other healthcare professionals as appropriate for clinical needs and in accordance with local framework/guidelines if indicated.
• Meet the needs of patients presenting for opportunistic long-term condition management or assessment.
• Be able to undertake medication reviews for individuals on any type of medication within an agreed skill level.
• Verification of expected death (where appropriate training and guidance allows).
• End of life - to support advanced care planning.
• Be able to undertake general telephone triage/first contact assessment.
• Manage own clinical workload within the Home Visiting Service, responding effectively to patient need.
• Work within the latest NMC/HCPC Code of Professional Conduct at all times.

Communication:

• Utilize and demonstrate sensitive communication styles, to ensure patients are fully informed and consent to treatment.
• Communicate effectively with patients and carers, recognizing the need for alternative methods of communication to overcome different levels of understanding, cultural background, and preferred ways of communicating.
• Anticipate barriers to communication and take action to improve communication.
• Maintain effective communication within the patient home environment and with external stakeholders.
• Act as an advocate for patients and colleagues.
• Ensure awareness of sources of support and guidance (PALS) and provide information in an acceptable format to all patients, recognizing any difficulties and referring where appropriate.

Delivering a Quality Service:

• Prioritize, organize, and manage own workload in a manner that maintains and promotes quality.
• Participate in quality assurance audits and safety processes across the organization and its activities.
• Participate in shared learning across the service and wider organization.
• Use a structured framework (root-cause analysis) to manage, review, and identify learning from patient complaints, clinical incidents, and near-miss events.
• Assess the impact of policy implementation on care delivery.
• Understand and apply legal issues that support the identification of vulnerable and abused children and adults, and be aware of statutory child/vulnerable patients health procedures and local guidance.
• Encourage patient feedback.

Team Working:

• Understand own role and scope and identify how this may develop over time.
• Work as an effective and responsible team member, supporting others and exploring the mechanisms to develop new ways of working.
• Delegate clearly and appropriately, adopting the principles of safe practice and assessment of competence.
• Create clear referral mechanisms to meet patient need.
• Prioritize own workload and ensure effective time-management strategies are embedded within the culture of the team.
• Work effectively with others to clearly define values, direction, and policies impacting upon care delivery.
• Discuss, highlight, and work with the team to create opportunities to improve patient care.
• Manage and lead on the delivery of specifically identified services or projects as agreed with the management team.
• Agree plans and outcomes by which to measure success.

Safeguarding Children and Vulnerable Adults:

All staff are expected to behave in such a way that supports the commitment of NPC to safeguard and promote the welfare of children, young adults, and vulnerable adults. You will be responsible for safeguarding the interests of children and adults who you come into contact during your work. To fulfill these duties, you will be required to attend training and development to recognize the signs and symptoms of abuse or individuals at risk, to follow local and national policy relating to safeguarding practice, and to report and act on concerns you may have appropriately.

Health & Safety / Management of Risk:

Manage and assess risk within the areas of responsibility, ensuring adequate measures are in place to protect staff and patients. Monitor work areas and practices to ensure they are safe and free from hazards and conform to health, safety, and security legislation, policies, procedures, and guidelines. Ensure appropriate supervision of safe storage, rotation, and disposal of vaccines and drugs, when required. Participate in mandatory and statutory training requirements. Apply infection control measures within the service, according to local and national guidelines. The post holder will comply with the Data Protection Act and the Access to Health Records Act Interpret national strategies and policies into local implementation strategies that are aligned to the values and culture of General Practice.

Information Governance:

Use technology and appropriate software as an aid to management in planning, implementation, and monitoring of care, presenting, and communicating information. Review and process data using accurate Read codes in order to ensure easy and accurate information retrieval for monitoring and audit processes. Manage information searches using the internet and local library databases. Understand responsibility of self and others to the Freedom and Information Act. Monitor and confirm that the nursing team are receiving and processing data and information in an agreed format. Collate, analyze, and present clinical data and information to the team.

Learning and Development:

Undertake mentorship for team members. Disseminate learning and information gained to other team members in order to share good practice and inform others about current and future developments (courses and conferences). Assess own learning needs and undertake learning, as appropriate. Provide an educational role to patients, carers, families, and colleagues in an environment that facilitates learning. Undertake and participate in clinical supervision sessions with the clinical lead.

Equality, Diversity, and Inclusion:

Identify patterns of discrimination and take action to overcome this and promote diversity and equality of opportunity. Enable others to promote equality and diversity in a non-discriminatory culture. Support people who need assistance in exercising their rights. Monitor and evaluate adherence to local chaperoning policies. Act as a role model in the observance of equality and diversity good practice. Accept the rights of individuals to choose their care providers, participate in care, and refuse care. Assist patients from marginalized groups to access quality care.

Sustainability and Carbon Reduction:

All staff are expected to work in a sustainable manner, demonstrating consideration for environmental issues and the adoption of alternative working practices where possible to contribute to carbon reduction.

Other Duties:

Any other duties, as agreed with the Service or Clinical Lead to meet the needs of the organization, may involve travel to other sites within the organization. You must hold a full driver's license with access to a vehicle to use for purposes of travel to and from Practices and to carry out home visits. This will involve having the appropriate insurance to use your vehicle for business use.

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