Job summary
Anexciting new opportunity has arisen for you to join the Urgent Care &Support Service at Your Healthcare as a Clinical Care Practitioner, Working inthe community to reduce hospital admissions from Nursing, Residential andLearning Disability care homes, enhancing MDT working and the use of UniversalCare Plans.
Thepostholder will support the implementation, management and delivery of enhancedMDT working in care homes across Kingston and work in partnership with carehomes, Care Home (GP) Leads, acute and community services to deliver, enhancedMDT working and increase the use of the Universal Care Plans.
Thepostholder will collaborate with professionals to initiate care planningdiscussions including advance care planning, comprehensive geriatricassessment, frailty, and dementia to initiate and complete a universal careplan.
Thisenhanced approach to MDT working and care planning aims to improve the use ofthe health and care system by intervening earlier, proactively, and moreholistically for residents of care homes.
Main duties of the job
Thepost will be fundamental in supporting the Care Home MDT meetings to functioneffectively, implement changes to ways of working and evaluate the success ofthe Proactive Anticipatory Care (PAC)model.
Work in collaboration with Health Care Professionalssupporting care home residents and to identify those at risk of deterioration,deconditioning or admission for discussion with the MDT, initiate or review ofadvance care plans through the UCP.
Monitor hospital admissions A&E attendance &ambulance call rates for care homes in the Kingston borough liaising with KHFTTransfer of Care Hub, Discharge Coordinators and other key personnel to enableproactive working and provision of targeted support to facilitate earlierdischarge and prevent unnecessary admission to hospital for care homeresidents.
Support care homes, linked GPs andAdult Services to work collaboratively to achieve effective communication andprovision of proactive medical/nursing/therapeutic care to facilitate earlierdischarge and prevent.
About us
Welcome to Your Healthcare CIC.We are a not-for-profit social enterprise, proud of delivering patient-led,high-quality health and social care community services for residents inKingston & Richmond as part of the NHS family.
As a Community Interest Company(CIC), we offer you NHS pay, conditions and training, but in a bureaucracy-freeenvironment where you can achieve things faster and see good ideas becomereality, quickly.
Your Healthcare is an equalopportunities employer and positively encourages applications from suitablyqualified and eligible candidates regardless of sex, race, disability, age,sexual orientation, gender reassignment, religion or belief, marital status, orpregnancy and maternity.
We are proud of our exceptionalstaff survey results, especially our staff engagement and good place to workscores, and our impressive feedback from patients and service users.
We are committed to promotingequality, diversity and inclusion for our staff members, service users,visitors, and carers, and we will encourage you to progress your career throughlearning and research.
We work closely andsuccessfully with other local providers and commissioners so that a wide rangeof high-quality, integrated health and social care services are available toour local community.
Job description
Job responsibilities
1. The postholder will support the ongoing implementation of integrated neighbourhood teams and MDT working in care homes across the Royal Borough of Kingston.
2. The postholder will work with within the Urgent Care & Support Service to support the implementation, management and delivery of enhanced MDT working in care homes across Kingston.
3. Care homes are supported by professionals from many different services, the postholder will work in partnership with care homes, Care Home (GP) Leads, acute and community services to deliver enhanced MDT working and increase the use of the Universal Care Plan.
4. The postholder will collaborate with professionals to initiate care planning discussions including advance care planning, comprehensive geriatric assessment, frailty and dementia to initiate and complete a universal care plan.
5. This enhanced approach to MDT working and care planning aims to improve the use of the health and care system by intervening earlier, proactively and more holistically for residents of care homes.
6. The postholder will support primary and community careto effectively deliver, implement and evaluate changes to ways of working.
Dimensions
7. Work in collaboration with Health Care Professionals supporting care home residents and to identify those at risk of deterioration, deconditioning or admission for discussion with the MDT, initiate or review of advance care plans through the UCP.
8. Monitor hospital admissions A&E attendance & ambulance call rates for care homes in the Kingston borough liaising with KHFT Transfer of Care Hub, Discharge Coordinators and other key personnel to enable proactive working and provision of targeted support to facilitate earlier discharge and prevent unnecessary admission to hospital for care home residents.
9. Support care homes, linked and Adult Services to work collaboratively to achieve effective communication and provision of proactive medical/nursing/therapeutic care to facilitate earlier discharge and prevent unnecessary hospital admissions
10. Collect data as required supporting audit focusing on health outcomes and reduction of acute hospital emergency bed days.
Key Responsibilities
11. Support GPs with their weekly ward round, proactively identifying residents who need attention and support care home staff to update Universal Care Plans as appropriate.
12. Participate in MDT meetings to help residents to navigate community and specialist services.
13. Challenge professional and organisational boundaries which prevent delivery of integrated health and social care to prevent health deterioration or hospital admission
14. Support the Urgent Care & Support Service with case managing patients with exacerbation of long-term conditions/complex conditions, enabling care homes to prevent crisis situations arising, thereby avoiding inappropriate hospital admissions
15. Support and develop a process of a seamless transfer of care between hospitals, care homes and community to ensure continuity of care
16. Support the care homes in developing Universal care plans (UCP) and crisis management plans with residents carers, relatives and health professionals based on full assessment of medical, nursing and social care needs
17. Support care homes with Advanced Care Planning, DNAR, Assessment of symptoms prescribing of EoL drugs and verification of death.
18. Empower care home staff in nursing homes to engage in difficult conversations with residents and families to facilitate Advance Care Planning.
19. Work in partnership with GPs, co-ordinating the seamless transfer of residents to appropriate services.
20. Be a point of contact for care home staff and professionals who visit the care home, such as GPs and in-reach specialists.
21. Support GPs with their weekly ward round, proactively identifying residents who need attention and support care home staff to update Universal Care Plans as appropriate.
22. Participate in MDT meetings to help residents to navigate community and specialist services.
23. Challenge professional and organisational boundaries which prevent delivery of integrated health and social care to prevent health deterioration or hospital admission
24. Establish a network that can be used to streamline care pathways, working in partnership with other agencies
25. Ensure effective co-ordination of care for individual residents within the care home setting
26. Link in with the care homes on a regular basis directly to ensure awareness of any new residents, discharges, deaths or hospital admissions etc.
27. Ensure care homes provide baseline health data if the resident is admitted to hospital to support integrated, consistent care and facilitate discharge
28. Work with the multi-disciplinary team to plan and implement high quality care.
29. Identifying patients who have complex care needs, formulating appropriate management plans and support care home staff with following management plans
30. To participate in working with care home staff to identify and manage residents with complex or long-term conditions, prevent admission to hospital and advising on nursing intervention to avoid deterioration.
31. Attend regular ward rounds with clinical leads from GP practices
32. Attend PCN Pharmacy meetings to ensure that the Clinical Pharmacists are aware of any new residents so that they can facilitate an SMR.
Communication
33. Use a high level of interpersonal, IT and communication skills to communicate effectively with residents and care home staff, including communication of sensitive and complex information about individual condition.
34. Effectively communicate at all levels of the organisation with a variety of health professionals, users and carers to provide the best health and social care outcomes for older people.
35. Provide the interface between hospital and Primary, Community & Social Care and Care Home settings
36. Maintain a high level of performance and be goal and outcome focussed when faced with opposition or when working under conditions of pressure.
37. Keep accurate timely documentation.
38. Provide high quality written reports and any other written documentation as necessary.
39. Listen and empathise with the needs and wishes of users and their carers.
Line Management
40. To ensure the smooth and efficient running of the service in partnership with the Advanced Nurse Practitioner/Urgent care & support service lead, the overall strategic direction and development of the Service.
41. To participate in the development and integration of care pathways, policies and procedures that will influence service delivery and practice.
Researcher
42. Evaluation of the project particularly in relation to impact
43. Identifying the population at risk within the care homes using local data and information from a variety of sources.
44. Critically evaluate and interpret evidence-based research finding from diverse sources making informed judgements about their implications for changing and/or developing services and clinical practice.
45. To support the Urgent care & support service to evaluate and audit the quality and effectiveness of the practice of self and others, selecting and applying a wide range of valid and reliable approaches and methods that are appropriate to needs and context
Person Specification
Experience
Essential
46. Negotiating and working across organisational boundaries
47. Working as part of a multi-disciplinary team
48. Mentoring students and other health care professionals
49. Experience of lone working and decision making
Desirable
50. Experience of working in care homes
51. Post registration and community experience of assessment and delivery of care to people with complex needs
Personal Qualities
Essential
52. Able to work under pressure
53. Self-motivated
54. Able to motivate others
55. Innovative
56. Enthusiastic
57. Able to work alone
Other factors
Essential
58. Valid driving license
Desirable
59. Be a car driver and have use of car
Knowledge
Essential
60. Knowledge of NMC Code
61. Knowledge of Universal Care plans
62. Understanding of national policy governing the delivery of adults and older peoples services
63. Awareness of current developments in health and social care
64. Knowledge of clinical governance/ risk management and reporting
65. An understanding of the implications of cultural difference for service delivery
66. Knowledge and understanding of audit and research
Desirable
67. Awareness of issues surrounding care homes
Skills & Abilities
Essential
68. Evidence of up-to-date based knowledge and skill
69. Evidence of ability to maintain high standards of care
70. Evidence of professional development and knowledge
71. Able to analyse situations and problem solve as necessary
72. Ability to develop and maintain partnership working
73. Ability to motivate staff
74. Report writing skills
75. IT Skills
Qualifications
Essential
76. Registered Level 1 Nurse
77. Diploma/Degree in nursing studies