Community Matron Complex Care at Home

2 weeks ago

Gloucester, United Kingdom Gloucestershire Health and Care NHS Foundation Trust Full time

Job summary

The Complex Care at Home service provides proactive, preventative case management to a mainly frail older cohort of patients living in Gloucester, Cheltenham and the Forest of Dean. This position is based in Gloucester, with the expectation you would support colleagues in other localities as required.

The team consists of Case Managers/Matrons who come from nursing and allied health professional backgrounds, complimented by physiotherapists, occupational therapists, dietitians, wellbeing coordinators, care navigators from adult social care, frailty housing officers and clinical support and advice from Consultant Geriatricians.

The skills required for the role include advanced clinical assessment skills and the ability to work autonomously. Experience of working in the community would be a distinct advantage and the ability and willingness to provide clinical support to other members of the team is essential.

You will have developed your enhanced clinical assessment and management skills and be confident in your approach to providing excellent clinical care to people living with complex clinical conditions. In return we can offer flexible work patterns and career development and progression.

The service uses a health coaching and motivational interviewing approach to their consultations, using "What Matters To You" as a basis to everything we do.

Main duties of the job

The post holder will work as a key part of the Integrated Community Teams having a clinical role with responsibility for planning, managing and co-ordinating the care of people with highly complex needs and long term conditions within a defined as a lead practitioner within a multidisciplinary team, proactively managing a caseload of complex patients living with long term conditions or frailty and at risk of deterioration.Patients will be identified through an agreed case finding approach.Support patients, carers and families to live well with their long term conditions to prevent avoidable health deterioration & hospital admission, or unnecessary length of stay through a case management approach.Responsible for the assessment of the health and social care needs, gather data and interpret complex clinical information in order to plan care appropriately.

The qualification, training & experience requirements for the role are underlined in the Job Description/Person Specification.

About us

We have in excess of 5000 staff working over 50 sites, providing a diverse range of services. We strive to support an organisational culture that is welcoming, builds and celebrates inclusivity and diversity and provides a sense of belonging and trust.

The annual NHS Staff Survey gives our people the opportunity to tell us about their experience working at the Trust. For the 2023 survey just over 2800 colleagues gave us their views ( It was great to see from the results that colleagues are saying that:

believe they are making a positive difference to patients/service users; would recommend the organisation as a place to work; agree that care of patients and service users is the organisations priority; would be happy with the standard of care for a friend or relative

Our results put us as 5th nationally as a Community, Mental Health and Learning Disabilities NHS Employer of Choice and 1st equal amongst all NHS Provider Trusts in the South West. However, we know we have more to do and will continue to drive forward our commitment to making GHC a Great Place to Work.

Job description

Job responsibilities

Work closely with the acute setting and the community teams to case find patients who would benefit from a case management approachEnsure an effective and evidence based service is delivered using advanced assessment and planning to be able to implement case management programmes for collaboratively with the patient, family and carers applying a coaching approach to problem solving and enabling appropriate self- management.Undertake a holistic assessment, care planning of identified patients, ensuring health gains and maximising independence

Person Specification

Qualifications

Essential

Level one Registered General Nurse or Allied Health Care Professional Current and valid registration with the relevant professional body Evidence of post-registration qualifications/experience at degree level or higher in managing complex long term conditions and frailty Qualification in, or working towards, Independent Non-Medical Prescribing Pathophysiology and Diagnostic Reasoning for Advancing Practice qualification (PADRAP) Qualification in Physical Assessment and Clinical Reasoning (PACR)

Experience

Essential

Significant post registration experience spent in a variety of settings including the community Experience in managing a complex clinical caseload Experience in managing difficult situations that require advanced communication and negotiating skills Experience of case management models of care including personalised goal setting, care planning and self-management plans and escalation plans Evidence in advanced comprehensive assessment including interpreting information, performing clinical interventions, diagnostics and analysing results.

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