YICT Nurse

Job summary

We are seeking to appoint a target driven individual with a can-doattitude to work as a Nurse as part of York Integrated Community Team /Frailty Hub.This key role is vital in providing a comprehensive care coordination tofacilitate the appropriate delivery of health care services whilst providing professional,competent and efficient care that meets patients health and social needs.

Working directly with the Frailty Hub you will support thismultidisciplinary team in the prevention of unnecessary hospital admission. Youwill also be case managing patients with frailty and long-term conditions to supportpatients to remain independent in their own homes, while continuing withhealthcare assessments, rehabilitation, and recovery.

In this busy challenging role you will be able to work on your owninitiative, be comfortable in making decisions within the scope of the rolewhilst demonstrating an understanding of community services and using theguidance and support of the multidisciplinary team.

Main duties of the job

To provide comprehensive care coordination in order to facilitate the appropriate delivery of health care services; integrating quality person centre care to improve patient outcomes. To provide professional, competent and efficient care which meets patients health and social needs and that promotes a reduction in the number of inappropriate hospital admissions. To Contribute to the Practice goal Providing the Best Clinical Care

About us

Nimbuscare is one of the largest 'at scale' providers of primary care inthe North of England, caring for more than 250,000 patients across our 11Member GP Practices.

We work collaboratively across the York area delivering new, innovative,and sustainable health care services.

As leaders in local care, our goal is to work together across the healthand care system to improve the health, wellbeing, and experience of ourpatients.

To learn more about Nimbuscare please visit our website at

In line with the General Data Protection Regulations (GDPR), Nimbuscarewill use and hold your personal data for the intended purpose.

We are committed to safeguarding the welfare of children/vulnerableadults and expect the same commitment from all staff and volunteers.

Nimbuscare is committed to improving the diversity of its workforce tobetter reflect the communities we serve. We welcome applications from everyoneand work to promote an inclusive supportive culture that values and celebratesour differences.

As a Disability Confident Committed employer disabled applicants whomeet the essential criteria for this job are guaranteed an interview.

Please noteNimbuscare does not hold a license to sponsor any visa applications and we areunable to provide any advice about visas.

Job description

Job responsibilities

Assistpatients through the healthcare system by acting as a patient advocate.

Toact as Care Coordinator for a cohort of patients; in order to meet patients'needs and preferences in the delivery of high-quality, high-value health care.Ensuring throughout that the patient's needs and preferences are known andcommunicated at the right time to the right people, and that this informationis used to guide the delivery of safe, appropriate, and effective care.

Deliverand delegate Patient-Centred care based on individual need.

Providesupport and advice to carers and HCA in assessment of patients and enable themto deliver evidence-based care.

Requiredto work from any surgery site or any other health care settings ( homevisits, in the community, as deemed necessary to the smooth running of thePractices

Requiredto offer on call telephone support to the wider team Out of normal workinghours on a rota basis.

Actas Mentor to Health Care Support team members helping to identity and deliverappropriate training.

Facilitatehealth and disease patient education.

Supportpatient self-management of disease and behaviour modification interventions

Coordinatecontinuity of patient care with external healthcare organizations andfacilities, including hospital admission and discharge and referrals from theprimary care provider to a specialty care provider.

Coordinatecontinuity of patient care with patients and families following hospitaladmission, discharge, and A&E visits.

Tomanage complex patients effectively and efficiently in their own home/care homecontributing to the work of the wider multidisciplinary team.

Towork within the Frailty Hub, assisting in the coordination of patient care todeliver appropriate and timely actions to prevent hospital admission.

Toliaise with all other community teams, eg primary care, secondary care, socialcare, and voluntary sector

Managehigh risk patient care, including management of patients with multipleco-morbidities or high risk for readmission to a hospital setting, including aregistry.

Conductcomprehensive assessments for patients and/or assist all support staff in dailypatient interactions as needed.

Promoteclear communication amongst the care team and treating clinicians by ensuringawareness regarding patient care plans.

Facilitatepatient medication management based upon standing orders and protocols.

Participatein York integrated care team multi-disciplinary team meetings.

Participateon a team for data collection, health outcomes reporting, clinical audits, andevaluation related to the Patient-Centred YICT initiative.

Evaluateclinical care, utilisation of resources, and development of new clinical tools,forms, and procedures.

Toensure any CQC requirements and/or documentation for which the post holder isresponsible for is completed timely and accurately. To also ensure anyprocedures and processes applicable to the role are followed timely andaccurately.

Toensure you devote the whole of your time at work, attention and abilities toyour role, our business, and its goals.

Tofacilitate the use of advance care plans within patients own home/care homesetting.

Actas named point of contact for patients and their carers.

Suchother duties as may reasonably be delegated from time to time.

Managecaseload autonomously to ensure targets are met.

Person Specification

Qualifications

Essential

Current NMC registration Safeguarding Children Level 2 Training Safeguarding Vulnerable Adults Training Certification of Enhanced Criminal Record Check with childrens and/or adults barred list check(s)

Experience

Essential

Experience of working in a Nurse role

Knowledge and Skills

Essential

Communication Skills: -Able to calmly, professionally and efficiently identify patients / internal customer needs -Able to professionally and efficiently deliver patients / internal customer needs with a warm reassuring demeanour -Able to skilfully signpost / refer the patient to the most appropriate person or alternative solution to their needs IT Literate: Competent in the use of Microsoft Applications and a proven ability to learn how to navigate and interrogate systems, input data with an attention to detail and follow processes and procedures

Capabilities and Attributes

Essential

Team Work: Work effectively and professionally within a surgery team, a wider clinical team and as an urgent care team through willingness to proactively support and assist their peers and colleagues. Autonomous: Ability to work independently by making informed decisions based on professional knowledge and clinical judgement. Time & Workload Management: The ability to quickly react to and manage changing, unpredictable and fluctuating workloads using a variety of methods of communication. The ability to recognise when a problem / issue should be escalated or referred for specialist investigation because it falls outside of the scope of the role and your professional knowledge. Can-Do Attitude: Ability to react to and face challenges or setbacks in a positive manner with a commitment to continuous improvement of their own skills and behaviours and also of the service Customer Service: Ability to remain focussed on providing and continuously improving an excellent internal customer service to the surgery team and clinical team(s) Deadline / Target Driven: Ability to work efficiently to strict deadlines and to be driven by the setting and achieving of individual and team targets Confidentiality: Ability to exercise and adhere to the Practice confidentiality policies Work Prioritisation: Ability to organise, prioritise and manage your own work demands by assessing levels of urgency and importance

Physical skills

Essential

Use of own car and driving licence

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