MDT Nurse Band 6
2 months ago
Job summary
The MDT Clinician play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide co-ordination and navigation of care and support across health and care services.
Work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to people and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.
This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.
The MDT Clinician role is intended to become an integral part of the PCNs multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN.
Main duties of the job
Work with people, their families and carers, to improve their understanding of their condition.
Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
Help people to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.
Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health.
Provide co-ordination and navigation for people and their carers across health and care services. Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time.
Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals
Support the co-ordination and delivery of multidisciplinary teams with the PCN.
About us
Sutton has a population of approximately 200,000 residents registered to 23 practices and there are currently 4 Primary Care Networks (PCNs); Carshalton, Cheam & South Sutton, Central Sutton and Wallington PCN; each serving a population of approximately 50,000 patients. PCNs form a key building block of the NHS long-term plan. Bringing general practices together to work at scale has been a policy priority for some years for a range of reasons, including improving the ability of practices to recruit and retain staff; to manage financial and estates pressures; to provide a wider range of services to patients and to more easily integrate with the wider health and care system. (The Kings Fund, Primary Care Networks Explained,
Our Sutton PCNs are forward-looking, friendly and focused on providing a wide range of excellent healthcare services to patients in Sutton and the surrounding PCNs between them are led 9 PCN Clinical Directors. The PCNs work together as they see the benefits of working together in a larger GP partnership and are delighted to be realising some of those benefits now. Because of our scale, not only are we more resilient and efficient but we are able to invest in continuous quality improvement, enhanced care, new services and training and developing our workforce. We value the diversity of our colleagues and actively champion an inclusive culture and are committed to helping our colleagues achieve a work/life balance.
Job description
Job responsibilities
Using clinical and nursing expertise determine that the patient is clinically optimised and that any acute episodes have resolved Identify and request appropriate assessment information as soon as the referral is received. Provide quality and clinical assurance for the assessment material, ensuring that it is appropriate and complete. If not, use sound clinical judgement to prioritise missing information required and refer to relevant professional in a timely manner. Ensure all additional information provided by an individual or their representatives is shared with the MDT in a timely manner. Identify appropriate individuals and secure their involvement as member of the MDT assessing eligibility Ensure the MDT meeting is arranged, coordinated, and communicated, with all necessary information available in a timely manner. Help MDT members to identify any significant gaps in information post assessment, and if so, assist in arranging for the necessary additional assessment information to be secured as soon as possible. Ensure all records are comprehensive, complete, available. Act as an impartial resource to the MDT, the individual undergoing assessment and/or their representatives on any policy or procedure questions that arise. If required, contribute to final decision-making of MDT eligibility recommendations in a fair, inclusive, and impartial way, utilising clinical knowledge. Must have a driving license and access to a car for home visits Adhering to all clinical governance standards, ensuring safe, efficient, and effective care, compatible with professional and national clinical standards. Attend relevant MDT meetings as required. Ensure that all MDT clinical policies are fully adhered to. Person Specification
Qualifications
Essential
Current NMC Registration RGN MDT Community Nurse Experience Membership of a professional body RCN Evidence of appropriate continuing professional development and education to maintain up to date knowledge
Desirable
Nursing Degree Qualification BSc or MSc or working towards Chronic Disease Management Qualifications ( Diploma, Degree) ENB 998 Teaching and assessing in clinical practice (or equivalent mentorship)
Experience
Essential
* Minimum of 3 years post graduate experience in a community or primary care setting * Experience of working in a multidisciplinary team * Understanding of MDT nursing role in primary care * Understanding of protocols and clinical guidelines * Good understanding of managing complex and changing conditions in patients. * Ability to manage change Understanding of developing MDT Services * Ability to support patients to change lifestyle * Good Understanding of clinical governance
Desirable
Willingness to participate in clinical supervision and performance review-
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