We are seeking to appoint a target driven individual with a can-do attitude to work as a Nurse as part of York Integrated Community Team / Frailty Hub. This key role is vital in providing comprehensive care coordination to facilitate 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 this multidisciplinary team in the prevention of unnecessary hospital admissions. You will also be case managing patients with frailty and long-term conditions to support patients to remain independent in their own homes, while continuing with healthcare assessments, rehabilitation, and recovery.
In this busy challenging role, you will be able to work on your own initiative, be comfortable in making decisions within the scope of the role whilst demonstrating an understanding of community services and using the guidance 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-centred 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 of providing the best clinical care.
Job Responsibilities
* Assist patients through the healthcare system by acting as a patient advocate.
* Act as Care Coordinator for a cohort of patients to meet patients' needs and preferences in the delivery of high-quality, high-value health care.
* Deliver and delegate Patient-Centred care based on individual need.
* Provide support and advice to carers and HCAs in assessment of patients and enable them to deliver evidence-based care.
* Required to work from any surgery site or any other health care settings (e.g., home visits, in the community, as deemed necessary to the smooth running of the Practices).
* Required to offer on-call telephone support to the wider team out of normal working hours on a rota basis.
* Act as mentor to Health Care Support team members helping to identify and deliver appropriate training.
* Facilitate health and disease patient education.
* Support patient self-management of disease and behaviour modification interventions.
* Coordinate continuity of patient care with external healthcare organizations and facilities, including hospital admission and discharge and referrals from the primary care provider to a specialty care provider.
* Coordinate continuity of patient care with patients and families following hospital admission, discharge, and A&E visits.
* Manage complex patients effectively and efficiently in their own home/care home contributing to the work of the wider multidisciplinary team.
* Work within the Frailty Hub, assisting in the coordination of patient care to deliver appropriate and timely actions to prevent hospital admission.
* Liaise with all other community teams, e.g., primary care, secondary care, social care, and voluntary sector.
* Manage high-risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting.
* Conduct comprehensive assessments for patients and/or assist all support staff in daily patient interactions as needed.
* Promote clear communication amongst the care team and treating clinicians by ensuring awareness regarding patient care plans.
* Facilitate patient medication management based upon standing orders and protocols.
* Participate in York integrated care team multi-disciplinary team meetings.
* Participate on a team for data collection, health outcomes reporting, clinical audits, and evaluation related to the Patient-Centred YICT initiative.
* Evaluate clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
* Ensure any CQC requirements and/or documentation for which the post holder is responsible for is completed timely and accurately.
* Devote the whole of your time at work, attention, and abilities to your role, our business, and its goals.
* Facilitate the use of advance care plans within patients' own home/care home setting.
* Act as named point of contact for patients and their carers.
* Such other duties as may reasonably be delegated from time to time.
* Manage caseload autonomously to ensure targets are met.
Person Specification
Qualifications
* Current NMC registration
* Certification of Enhanced Criminal Record Check with children's and/or adults barred list check(s)
Experience
* Experience of working in a Nurse role
Knowledge and Skills
* 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/referral 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
* 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 focused 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
* Use of own car and driving licence
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
£33,000 to £35,300 a year dependent on experience.
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