Do you have experience in long term conditions management in the community? Have you had experience managing care home patients or patients with frailty needs? Are you working at a level 7 (post grad) certification? If so - come and join our great supportive Home Visiting Team in Canterbury! We work in an integrated and collaborative way with Canterbury GP practices. We are proud of the services we provide and passionate about improving and developing them further.
Main duties of the job
Support the delivery of Enhanced Health in Care Homes. Provide an alternative model to urgent and same day GP home visits supporting the Canterbury PCNs. We would expect you to be able to perform specialist health checks and reviews within your scope 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 responsibilities will evolve so this is not designed to be an exhaustive list.
The role includes:
* Support the delivery of Enhanced Health in Care Homes including:
o Assessment upon admission of new patients to care homes
o Proactive, timely and consistent weekly support to the care home
o Evaluate and modify care plans
o Timely same day response to the in-reach teams where appropriate
o Provide direct clinical care to patients using established clinical guidelines for both routine and urgent complaints.
Working as part of a multi-disciplinary team within Canterbury Integrated Healthcare including involvement in weekly frailty and/or care home MDT meetings.
Assess and triage patients, including same day triage, and as appropriate provide definitive treatment (including following patient group directives, NICE (national) and local clinical guidelines and local care pathways) or make necessary referrals to other members of the PCN team.
Anticipatory care planning to include ReSPECT discussions and development of Personalised Care and Support Plans.
Advise patients on general healthcare and promote self-management where appropriate, including signposting patients to the PCNs social prescribing service and, where appropriate, other community or voluntary services.
Liaising with other professionals, families and carers to provide clinical information relating to patient management.
Be able to:
* Perform specialist health checks and reviews within their scope of practice and in line with local and national guidance.
* Lead certain services (e.g., monitoring blood pressure and diabetes risk of elderly patients, reviews of patients with learning disabilities).
* Provide an alternative model to urgent and same day GP home visits for the networks.
* Communicate at all levels across organisations ensuring that an effective, person-centred service is delivered.
* Communicate proactively and effectively with all colleagues across the multi-disciplinary team, attending and contributing to meetings as required.
* Maintain accurate and contemporaneous health records appropriate to the consultation, ensuring accurate completion of all the necessary documentation associated with patient healthcare and registration with the organisation.
* Communicate effectively with patients and, where appropriate, family members and their carers, where applicable, complex and sensitive information regarding their physical health needs, results, findings and treatment choices.
Any other tasks and duties commensurate with 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.
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