Do you have experience in long term conditions management inthe community? Have you had experience managing care home patients or patientswith frailty needs? Are you working at a level 7 (post grad)certification? If so - come and join our great supportive Home Visiting Team inCanterbury! We work in an integrated and collaborative way with Canterbury GP practices.We are proud of the services we provide and passionate about improving anddeveloping them further.
Main duties of the job
Supportthe delivery of Enhanced Health in Care Homes. Provide an alternative model tourgent and same day GP home visits supporting the Canterbury PCNs. We wouldexpect you to be able to perform specialist health checks and reviews within yourscope of practice and in line with local and national guidance.
About us
Canterbury Integrated Healthcare supports the 7 Canterbury practices and their PCNs covering a patient population of around 100,000 and we have worked together for many years
The local care vision in East Kent is for localities to develop a model of care that enables people to live as independently as possible by delivering high quality, person centred care that integrates hospital, social care, community and voluntary services around primary care networks of GP practices.
The vision for Canterbury is for the two PCNs to work together to achieve excellent patient care through integrated pathways accessed close to home via local GP practices.
The Canterbury PCNs will achieve this by delivering primary care at scale, including:
* Engagement from all practices within the City in the Integrated model of care
* Partnership working with other PCNs, NHS Trusts, community providers and the voluntary sector
* A comprehensive workforce strategy including engagement with the new medical school for Kent and Medway and the new Additional PCN roles.
We aim to work collaboratively with other healthcare providers and support organisations, to enable more patients to be treated in a primary care setting, closer to home.
Job responsibilities
It is important to note that responsibilitieswill evolve so this is not designed to be an exhaustive list.
The role includes:
Support the delivery of Enhanced Healthin Care Homes including:
oAssessment upon admission of newpatients to care homes
oProactive, timely and consistent weeklysupport to the care home
oEvaluate and modify care plans
oTimely same day response to the in-reachteams where appropriate
oProvide direct clinical care to patientsusing established clinical guidelines for both routine and urgent complaints.
Working as part of a multi-disciplinaryteam within Canterbury Integrated Healthcare including involvement in weeklyfrailty and/or care home MDT meetings
Assess and triage patients, includingsame day triage, and as appropriate provide definitive treatment (includingfollowing patient group directives, NICE (national) and local clinicalguidelines and local care pathways) or make necessary referrals to othermembers of the PCN team
Anticipatory care planning to includeReSPECT discussions and development of Personalised Care and Support Plans
Advise patients on general healthcare and promote self-management where appropriate, including signpostingpatients to the PCNs social prescribing service and, where appropriate, othercommunity or voluntary services
Liaising with other professionals,families and carers to provide clinical information relating to patientmanagement.
Be able to:
oPerform specialist health checks andreviews within their scope of practice and in line with local and nationalguidance
oLead certain services (e.g., monitoringblood pressure and diabetes risk of elderly patients, reviews of patients withlearning disabilities)
oProvide an alternative model to urgentand same day GP home visits for the networks
oCommunicate at all levels acrossorganisations ensuring that an effective, person-centred service is delivered
oCommunicate proactively and effectivelywith all colleagues across the multi-disciplinary team, attending andcontributing to meetings as required
oMaintain accurate and contemporaneoushealth records appropriate to the consultation, ensuring accurate completion ofall the necessary documentation associated with patient healthcare andregistration with the organisation
oCommunicate effectively with patients and,where appropriate, family members and their carers, where applicable, complexand sensitive information regarding their physical health needs, results,findings and treatment choices
Any other tasks and duties commensuratewith the role
Person Specification
Qualifications
* Registered with the appropriate professional council
* Level 7 or above postgraduate certification
Other Requirements
* Access to own transport and ability to travel across the locality
* Flexibility to work outside of core hours when required
* Ability to work remotely when required
Personal Qualities
* Drive to provide excellent integrated patient care
* Ability to work collaboratively in a team
* Flexible approach to the evolving nature of the role
* Ability to sometimes work under pressure to meet deadlines
* Ability to reflect upon own performance and consider improvements
Experience
* Excellent interpersonal and communication skills
* Time management and ability to prioritise workload
* Ability to work autonomously and use own initiative
* Ability to assess and manage risk when working with individuals
* Experience of working with patients in their own homes or a care setting
* Experience in community or frailty sectors
* Experience in managing Long Term Conditions
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.
The Annexe (Next door to Canterbury Medical Practice)
The Annexe (Next door to Canterbury Medical Practice)
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