An exciting opportunity has arisen for a 1 Year secondment starting in April 2025 to cover the West and North Norwich Case Manager post.
The team provide advanced case management and clinical nursing care to patients with long term conditions who are often high intensity users of both primary and secondary care. You will work closely with PCN and NCHC community team colleagues to assess and provide advanced level interventions for patients with long term conditions. The team supports admission avoidance through joint working with our community virtual ward team, High Intensity User Service Team, and links with our colleagues at Norfolk & Norwich University Hospital to facilitate supported discharge.
The successful applicant will be expected actively look for, and progress, opportunities to improve and develop the service, working with our system partners to support patient autonomy.
To provide case management to patients over the age of 65 years who may have one or more unstable long term condition; had a recent fall; a recent unplanned admission to hospital; cognitive impairment, dementia and / or depression and have multiple contacts with health and social care.
Apply now to join an organisation that has been awarded an ‘Outstanding’ rating by the Care Quality Commission (CQC), the highest possible rating and the first stand-alone NHS community trust in the country to be awarded the title.
Find out more about working for our organisation here:
1. The post holder will assess the patients’ holistic needs, communicating complex and
sensitive information to the patients and carers relating to their assessment, diagnosis, prognosis and treatment plan.
2. Following a holistic assessment, the post holder will plan and devise an individualised care programme for each patient.
3. The post holder will ensure informed consent is obtained prior to initiating interventions.
4. The post holder will implement and deliver a treatment/care plan utilising a range of options.
5. The post holder will evaluate the care/treatment plan on an ongoing basis and modify it as required.
6. The post holder will be aware of Assistive Technology and utilise where required for the benefit of the patient.
7. Where there are barriers to a patient or carers understanding, such as hearing impairment, mental capacity impairment and other difficulties in comprehension, the post holder will adjust their explanations in order that the patient or carer can gain
understanding, consent and concordance with the information presented.
8. The post holder will be required to use tact and persuasive skills in order to gain the
patient’s co-operation in their treatment/care/management plan.
9. The post holder will liaise with GPs, Social Services, inpatient teams, other allied
health care professionals and the voluntary sector to ensure that the patients
identified needs are met and their care co-ordinated appropriately.
10. The post holder will contribute to Personal Health Plans as required.
11. The post holder will participate in multi-disciplinary/multi-agency meetings as
appropriate, e.g. Gold Standard Framework.
12. Plan and organise specialist services within the integrated team.
13. The post holder will ensure that activity data and clinical information is recorded on
SystmOne and completed on a daily basis in line with Trust Policy.
This advert closes on Friday 14 Feb 2025
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