Job summary An opportunity has arisen in the Integrated Care Team (ICT) in North East Hampshire (namely Aldershot, Farnborough and Fleet localities) among a well-established and effective multidisciplinary team. This is a highly rewarding role, where clinicians can dedicate quality time to understanding their patients and what matters to them. The integrated approach ensures patients who require a bespoke level of care and support in the community are looked after by the right team and will only need to tell their story once. Patients under the care of the ICT have the peace of mind that the teams supporting them do so with a joined-up and patient centred approach. The ICT Nurse will assess patients in the community setting and work among wider multidisciplinary team colleagues to form innovative care plans to support identified needs. In addition, the Nurse will participate in a rota of clinical triage in our vibrant Community Services Referral Hub and the completion of proactive frailty assessments providing variety and balance to the working week. Main duties of the job Holistic bespoke assessment of patients in their own homes, establishing a baseline overview of health, clinical, mental health, and environmental needs, guided by clinical templates Support and input to care planning and collaborative decision making alongside community service colleagues including Community Nurses, Mental Health Practitioners, Specialist Nurses, Community-Based Therapy Teams,Social Prescribers, Adult Social Care, Hospice Services and Home Visiting Paramedic Practitioners Leads and participates in multidisciplinary care team meetings Clinical Triage, supported by robust protocol and clinical templates, in our Community Single Point of Access (CSPA) Proactive assessment of patients in their own homes, to identify the increasingly frail patient in an attempt to input support prior to any further decline in health, social and care needs. Subsequent participation and coordination of a dynamic Consultant-Led multidisciplinary meeting to agree care plans of action. About us Salus is a GP Federation which was formed by the local GP practices within North East Hampshire and Farnham. This Includes practices located in Aldershot, Farnborough, Fleet, Farnham & Yateley. We hold several contracts supporting primary care to deliver services on behalf of those practices, helping them work better together and with other healthcare providers leading to improved patient services and developing new ones due to constant changes in the Primary Care environment. Salus also assists practices with admin, operational and HR support and facilitates shared learning across localities. By engaging with the public, we also help ensure that services are designed and developed with patient and public involvement. The staff at Salus Medical Services have a wealth of experience working in general practice and therefore a good understanding of the opportunities and challenges faced. The Salus ICT is made up of 7 trained Nurses, 3 Clinical Associates, a Care Coordinator, and a team of 5 effective administrators. We are a welcoming, friendly and responsive team. Our vision is to provide a service which supports and guide patients through complex and challenging circumstances, in true collaboration with our valued partner organisations. Staff wellbeing and a positive working environment is instrumental to what we do. It is our belief that our approach to patient care is only enhanced when our staff feel happy, healthy and safe. Date posted 11 February 2025 Pay scheme Other Salary Depending on experience Contract Permanent Working pattern Full-time Reference number U0042-25-0000 Job locations Aldershot Centre For Health Hospital Hill Aldershot Hampshire GU11 1AY Job description Job responsibilities The post holder will work as part of the Integrated Care Team and will share responsibility for the Triaging of patient referrals into the Locality Access Point for both the Integrated Care Team and wider community services. The post holder will undertake Integrated Care Team assessments within the community setting focusing specifically on those patients proactively identified as requiring Anticipatory Interventions/Frailty. The post holder must be able to demonstrate the ability to complete a comprehensive assessment and have an understanding of Frailty as a recognised syndrome. The postholder will partake in both the Integrated Care Team Meetings and Anticipatory Interventions Meeting and demonstrate an ability to communicate effectively with wider members of the Multidisciplinary Team and service users. The post holder will be responsible for completing onward referrals within both health and social care settings and liaising as required with services. Share the responsibility for the day to day running of the caseload with other members of the Integrated Care Team. Liaise with relatives, carers and health care professionals to prevent and minimise the risk of acute hospital admission where appropriate, working in partnership with secondary care discharge co-ordinating services. Must be autonomous in practice Ensure resources are utilised in a cost-effective manner. Ensure all professional/clinical practices are in line with Salus policies Ensure appropriate and accurate records are maintained. Be accountable for own professional actions according to NMC Code of Professional Code. Maintain your Continuous Professional Development according to NMC Code of Professional Code and Revalidation requirements. Job description Job responsibilities The post holder will work as part of the Integrated Care Team and will share responsibility for the Triaging of patient referrals into the Locality Access Point for both the Integrated Care Team and wider community services. The post holder will undertake Integrated Care Team assessments within the community setting focusing specifically on those patients proactively identified as requiring Anticipatory Interventions/Frailty. The post holder must be able to demonstrate the ability to complete a comprehensive assessment and have an understanding of Frailty as a recognised syndrome. The postholder will partake in both the Integrated Care Team Meetings and Anticipatory Interventions Meeting and demonstrate an ability to communicate effectively with wider members of the Multidisciplinary Team and service users. The post holder will be responsible for completing onward referrals within both health and social care settings and liaising as required with services. Share the responsibility for the day to day running of the caseload with other members of the Integrated Care Team. Liaise with relatives, carers and health care professionals to prevent and minimise the risk of acute hospital admission where appropriate, working in partnership with secondary care discharge co-ordinating services. Must be autonomous in practice Ensure resources are utilised in a cost-effective manner. Ensure all professional/clinical practices are in line with Salus policies Ensure appropriate and accurate records are maintained. Be accountable for own professional actions according to NMC Code of Professional Code. Maintain your Continuous Professional Development according to NMC Code of Professional Code and Revalidation requirements. Person Specification Qualifications Essential NMC Registered Nurse Knowledge and skills Desirable Experience within both Secondary and Primary Care Setting. Excellent communication skills and the ability to work as part of a team. IT Skills. Person Specification Qualifications Essential NMC Registered Nurse Knowledge and skills Desirable Experience within both Secondary and Primary Care Setting. Excellent communication skills and the ability to work as part of a team. IT Skills. 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. UK Registration Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window). Additional information 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. UK Registration Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window). Employer details Employer name Salus Medical Services Ltd Address Aldershot Centre For Health Hospital Hill Aldershot Hampshire GU11 1AY Employer's website http://www.salusmedical.co.uk/ (Opens in a new tab)