Community Practitioner- Intensive Home Support Service

Job summary

An exciting opportunity has arisen for two enthusiastic, motivated and committed Community Practitioners to join the Intensive Home Support Service (IHSS).

To support the Senior Practitioner to proactively case manage high risk patients with chronic long term conditions and complex health and social needs to avoid unnecessary hospital admission. Working closely with an integrated neighbourhood team, primary care services and local GP practices.

The post holder will provide clinical assessment, identification, planning, case management and co-ordination of care for people with long term conditions who have complex needs and co-morbidities. The post holder will work towards enhanced professional practice including medicines management, professional leadership, improving mental health and supporting and promoting a self-care management model.

The post-holder will promote partnership working to improve outcomes for patients with co-morbidity of long-term conditions in order to reduce unplanned hospital admissions, reduce length of stay, and facilitate seamless transition of care. The post holder will join a rotational rota covering shifts over a 24 hour period, 7 days per week, 365 days per year.

Main duties of the job

To support the Senior Practitioners to proactively case manage high risk patients with chronic long term conditions and complex health and social needs to avoid unnecessary hospital admission. Working closely with an Integrated Neighbourhood Team, Primary Care Services and local GP practices.

The post holder will provide clinical assessment, identification, planning, case management and co-ordination of care for people with long term conditions who have complex needs and co-morbidities.

The post holder will work towards enhanced professional practice including medicines management, professional leadership, improving mental health and supporting and promoting a self-care management model. The post-holder will promote partnership working to improve outcomes for patients with co-morbidity of long term conditions in order to reduce unplanned hospital admissions, reduce length of stay, and facilitate seamless transition of care.

The post holders will contribute to a rota working over 24 hours, 7 days a week on a rotational basis.

About us

At East Lancashire Hospitals Trust, our vision is to be widely recognised for providing safe, personal and effective care. We currently provide high quality services and treat over 600,000 people across East Lancashire and the surrounding area. We employ over 7,000 staff, many of whom are internationally renowned and have won awards for their work.

We have 2 main hospital sites in Blackburn and Burnley along with peripheral community sites.

Job description

Job responsibilities

Provide comprehensive programmes of care, under the supervision of a Senior Practitioner that promote health gains, reduce risks to health and well-being, short term and long term and maximise independence of client and patient with co-morbidity long term conditions. This will include:- Health and social assessment including medical history and clinical examination. Diagnosis and exercising independent prescribing in accordance with appropriate legislation and ELHT protocols. Functional/cognitive assessment. Ensuring that client values, beliefs and views, are reflected in their management plan. Under the supervision of the Senior Practitioner co-ordinate care and treatment to avoid fragmentation, duplication and delay in the least intensive setting appropriate to the clients needs by: Requesting and interpreting diagnostic investigations in order to implement and review a programme of care to meet the needs of the client. Referring to specialist services. Ensuring effective communication and sharing of appropriate information amongst professionals to avoid conflicting treatments. Identifying deficiencies in service provision and addressing these appropriately. Use developing skills and knowledge to instigate therapeutic treatments consistent with best available evidence with appropriate input from multidisciplinary teams and other agencies. Be proactive in the rigorous monitoring and evaluation of the effectiveness of agreed care management plans, providing timely interventions and modifications as necessary in partnerships with clients/patients. Promote and improve the patients self-management of their condition wherever possible. Take an active role in the promotion of health and the prevention of ill-health Work collaboratively across organisational boundaries Health, social Care, voluntary and Independent sector to support the effective provision of health and social care services developing a robust partnership approach. Create, maintain and facilitate effective multi-disciplinary team working to ensure that the care delivered to service users is quality driven. Ensure that care and services are delivered in line with all relevant NSFs, CQC guidance, NICE guidelines, professional requirement, ELHT policies and procedures, Standards for Better Health and current legislation. Identify and critically appraise contemporary evidence, develop and promote best practice, ensuring strong professional leadership. In liaison with the Integrated Clinical Lead and the Senior Practitioner, work within established models of practice that monitor and maintain high clinical standards for self and others within the care environment. Participate in and promote Clinical supervision in practice Be a role model for the delivery of clinical and professional practice that will enable innovative and creative practice development. Act as an ambassador for the ELHT ensuring that systems are in place to share knowledge, expertise and examples of good practice across the partnership arena. Provide leadership for the protection of children and vulnerable adults, ensuring that individuals within the care environment comprehend their responsibility. Promote ELHTs vision and public health priorities. Support the clinical managers and work with the Integrated Clinical Lead in the delivery of the clinical governance, quality improvement and performance management agenda across provider services. Ensure that all clinical records are maintained at the standard required by ELHT and GP practice, identifying assessments made, treatments given and course of action planned. Have in depth knowledge of relevant professional standards and guidance, understand implications for and be able to apply to practice Code of Professional Conduct, standards for conduct, performance and ethics. Record Keeping. Standards of proficiency for nurse and midwife prescribers. Standards to support learning and assessment in practice. Be responsible for ensuring that the service is delivered in line with ELHT and other relevant policies in relation to Health & Safety and infection control. Maintain the confidentiality of patients and their carers in the with Caldicott requirements. Person Specification

Qualifications

Essential

Degree in appropriate subject or evidence of education to degree level. Current NMC / HCPC registration - Registered General Nurse / Physiotherapist / OT

Desirable

Non-medical prescribing V300 or working towards Clinical Examination and Clinical Diagnostic CPD Modules at Masters level or evidence of working to that level or currently working towards

Experience

Essential

Up-to-date evidence of continuing engagement in professional development and of reflective practice in a professional portfolio Evidence of supervising team members Evidence of experience working in partnership and collaboration

Desirable

Evidence of clinical experience at a high level in a range of clinical settings including the community/primary care setting. Experience of working with complex cases Evidence of experience in mentoring/teaching role. Participation in research, audit and evaluation Leading change and innovation

Knowledge

Essential

Enhanced clinical knowledge including current evidence-based practice Competent to assess patient's requirements to develop case management plans. Knowledge of Chronic Disease Management and long term conditions COPD, Heart Failure and COPD Sound understanding of the expectations of a case manager for long term conditions, particularly in terms of service outcomes and their relevant context. Good understanding of systems in health and social care that are wider than immediate role Able to plan proactively, manage and evaluate own learning, to negotiate learning opportunities and establish learning contracts Demonstrates excellent written and verbal communication skills Analytical and problem solving skills Ability to maintain records, statistical and activity data in line with trust standards Time management and organisational skills Knowledge and understanding of the principles of governance and its implications to their service area. Ability to work effectively as part of a team Good IT skills, including those of using internet based communications and literature.

Desirable

Ability to interpret data from diagnostic tests to adjust interventions appropriately Demonstrate an awareness/understanding of the factors that contribute to good health and the public health priorities of East Lancashire Hospitals Trust Ability to communicate complex information where agreement and co-operation is required with clients, carers, staff, colleagues and other professionals. Advanced counselling and communications Ability to analyse, interpret and present data

Personal Attibutes

Essential

A constructive, inquiring, flexible approach to others and to their work Self-confidence to challenge traditional practice and the persistence to address difficult, enduring issues. Self-motivated and adaptable with changes being implemented Demonstrates the need to maintain confidentiality and respects diversity and ethnicity. Flexible working- able to contribute to a 24hour rotational rota The post holder must be assessed as having a level of fitness to carry out duties/tasks after reasonable adjustments under the terms of disability discrimination act have been made. A current driving licence

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