Job summary
This post is fixed term for 18-months, when it will be reviewed in line with the needs of the service.
The South East Wellbeing Centre, Cardiff (SEWeCC) service is a new multidisciplinary and multiagency collaborative initiative within C&VUHB aimed at coordinating the proactive and holistic management of patients whose needs may be better supported through the intervention of council, community and /or third sector services as a supplement to GP care and supported by health and social care professionals.
We are committed to ensuring that every patient receives the highest standard of care and support throughout their healthcare journey and as part of our commitment to excellence, we are seeking a dedicated and experienced Cluster Frailty & Chronic Conditions Practitioner to join our SEWeCC team.
This is a fixed term for 18 months due to funding
Main duties of the job
Case manage an identified group of people with long term conditions/complex needs to support the prevention of unplanned hospital admissions, responding to patients who require urgent assessments and in collaboration with the patient, General Practitioner (GP) and Primary Care and community teams/social services, set up management plans with the aim of stabilising the individual's condition, enabling the patient to stay at home where possible.
Inform, teach and mentor patients and their families with the aim of improving the patient's ability to understand and manage their long-term conditions.
Work in partnership with the South East Wellbeing Centre, Cardiff across the cluster areas and collaborate with colleagues within the NHS and partner organisations to develop a consistent local multi-agency approach to managing long term conditions.
Advanced care planning to improve communication and facilitate the co-ordination of patient care for those over 18 years of age at any stage of their health by involving the most appropriate professionals from health and social care, together with third sector providers. This will promote conversations between people, their families, carers and those looking after them, about their priorities, needs and preferences about their care now and in the future, enabling the relevant support to be provided enabling the appropriate delivery of care to meet these needs.
About us
Cardiff and Vale University Health Board is one of the largest Integrated Health Boards in the UK, employing over 15,000 staff, providing over 100 specialist services. Working across 6 hospital sites, we have a diverse range of career opportunities to offer. Serving around 500,000 people living in Cardiff and the Vale of Glamorgan, we are focussed on the health and care needs of our local population whilst working with our partners to develop regional services.
Our mission is "Caring for People, Keeping People Well", and our vision is that every person's chance of leading a healthy life should be equal. As an organisation we are unashamedly ambitious for our population's health, rising to the challenges of today and tomorrow through our 10-year strategy, Shaping our Future Wellbeing. We are contributing to a healthier Wales with great emphasis placed on innovation and improvement, learning from around the world and leading the way in clinical research. Partnership working is strong at Cardiff and Vale, and we work closely with our staff and our community.
Cardiff, the thriving Welsh capital, is a fantastic city to live and work in with an abundance of sports, arts and cultural attractions. Situated to the west of Cardiff, the Vale of Glamorgan offers a combination of beautiful Welsh countryside and a dramatic natural coastline. Whether city life or rural living, Cardiff and the Vale offers the best of both worlds.
Job description
Job responsibilities
Use advanced nursing skill and expert knowledge to assess the physical and psychosocial needs of a defined client group, instigating treatment based on best available evidence in order to stabilise the individuals condition.
To agree a personal management plan with the patient, ideally with inclusion of carers, relatives and other appropriate health care professionals. This will be based on a full assessment of medical, nursing and basic social care needs.
To use advanced nursing skills and expert knowledge to identify subtle changes in the patients condition, analysing and interpreting complex health problems and associated scenarios.
To work with patients to identify problems from their perspective and develop holistic management plans.
To negotiate and agree with clients, carers, community nurse teams and other care professionals, individual roles and responsibilities with actions to be taken and outcomes to be achieved, referring on to other services or professionals as appropriate.
To work across professional and organisational boundaries, identifying areas for skill and knowledge development applying these to individual practice with the aim of providing continuity and high-quality patient centred care.
To enable patients and carers to manage their medications in conjunction with GPs, Pharmacists and other relevant clinical staff, including medication reviews as part of initial assessments and ongoing patient reviews.
To provide expert clinical care and health promotion.
Use expert knowledge and skill as a non-medical prescriber to independently prescribe within the individual practitioners areas of prescribing competency.
Develop prescribing clinical management plans as appropriate in partnership with GP colleagues.
Advanced care planning to improve communication and facilitate the co-ordination of patient care for those over 18 years of age at any stage of their health by involving the most appropriate professionals from health and social care, together with third sector providers. This will promote conversations between people, their families, carers and those looking after them, about their priorities, needs and preferences about their care now and in the future, enabling the relevant support to be provided enabling the appropriate delivery of care to meet these needs.
Work to the NMC code of practice and maintain professional
Person Specification
Qualifications
Essential
1. RN First level Nurse.
2. 1st level Degree or equivalent skills, knowledge and experience.
3. Teaching and assessing qualification or equivalent demonstrable experience.
4. Non-medical prescriber / supplementary prescribing (or prepared to undertake training within 12 months of commencing role).
5. Evidence of continuing professional development in a relevant area of specialist practice to Master's equivalent level.
6. Good knowledge of anatomy and physiology.
7. Up to date working knowledge of both local and national policy issues pertinent to adults with long term conditions legislation and disease management.
Experience
Essential
8. Experience of working as an autonomous practitioner.
9. Case management experience.
10. Working with adults with long-term conditions.
11. Good understanding of working in partnership with statutory and non-statutory agencies to support patient centred care.
12. Multi-disciplinary and multi-agency working.
13. Proven extensive experience of working with adults/older people.
SKILLS & COMPETENCIES
Essential
14. Communication & Relationship Skills
15. Analytical & Judgement Skills
16. Planning & Organisational Skills
SPECIAL KNOWLEDGE
Essential
17. Evidence of the ability to work in a changing stressful situation.
18. Advanced clinical decision-making skills to support patient centred care.
19. Extensive experience in working with adults and older people, including adults with long term conditions.
20. Evidence of ability to maintain and monitor high standards of care.
21. Computer literate.
22. Good keyboard skills.
KNOWLEDGE
Essential
23. Professional knowledge acquired through degree/diploma supplemented by specialist training, experience, and short courses.
24. Up to date knowledge of legislation, policy and professional issues pertinent to the area of specialism and its contexts.
25. Specialist knowledge in relation to working with adults and older people, including adults with long term conditions.
PERSONAL QUALITIES
Essential
26. Professional attitude.
27. Able to focus and concentrate on complex issues on a daily basis and deliver high quality outcomes.
28. Able to work consistently and professionally with frequent exposure to highly emotional, distressing and sensitive clinical circumstances.
29. Practices equal opportunities and respect for others.
OTHER
Essential
30. Must be mobile for regular travel and able to travel between base and client homes within a reasonable timeframe and cost.
31. Satisfactory DBS Check