An exciting opportunity has arisen for a Community Matron to support our West Norwich patients.
The team provides 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 to actively look for and progress opportunities to improve and develop the service, working with our system partners to support patient autonomy.
Main duties of the job
The Community Matron role is to provide advanced, intensive case management and clinical nursing care to patients predominantly in their home settings, including residential homes and supported living complexes.
The workload requires a good range of clinical skills to be applied in managing our patients with chronic unstable conditions, including assessment and provision of advanced level interventions for patients with long-term conditions to achieve quality of life and independence where possible.
There is an expectation that the Community Matron will support Community Nurses in the team, as well as students and apprentices in the role of an assessor or supervisor.
Job responsibilities
1. To assess and provide advanced level interventions for patients with long-term conditions to achieve quality of life and independence where possible, and to support them in their own environment.
2. To work within the integrated team to facilitate early discharge from hospital.
3. To work in conjunction with Norwich Practices supporting the Home Visiting Service with long-term condition management.
4. To work within the integrated team to prevent unnecessary admission to hospital with adequate management plans and clear guidance.
5. To work with all health care professionals, and statutory/non-statutory agencies to provide a seamless, integrated service to our service users.
6. To support patients in coordinating their personal health plans.
7. To assess patients for assistive technology where appropriate.
8. To refer on to social care support where appropriate.
9. To support and manage Band 6 Case Managers.
10. Track patients who are part of the Community Matron caseloads when entering hospital or nursing home step-up beds and ensure that they are followed up appropriately when discharged.
11. Working closely with GPs and the acute hospital and support service issues that may need resolving to ensure timely discharge.
12. Proactively find patients who are very high-intensity users of primary and secondary healthcare and/or are at high risk of unplanned admission to hospital.
13. Educate and support the members of the multi-disciplinary teams to intensively case manage these patients.
14. Intensively manage their own caseload of patients with highly complex and unstable health needs.
15. Independently manage the caseload by maintaining a consistent throughput of patients, ensuring timely discharge, promoting patient independence, and encouraging self-care.
16. Develop systems and processes to support intensive case management within the multidisciplinary team and with partners across the health system.
17. Accountable for the intensive case management and where appropriate intervention of a defined patient caseload.
18. Be a champion for people with long-term conditions.
19. Provide supervision and assessment for all learners as part of trust educational policy, particularly those undertaking pre/post registration nursing courses.
Person Specification
Qualifications
Essential
* 1st Level degree RN qualification
* Assessor/Mentorship preparation
* Current NMC Registration
* Evidence of continuing professional development related to a long-term condition such as COPD, Heart Failure etc.
* Master's Degree or willingness to work towards
* CPD qualifications incorporating Advanced Clinical Practice and Independent Prescribing (or willingness to undertake)
* Independent/supplementary prescribing qualification
Experience
Essential
* Post qualification experience including previous experience at Band 6 level or above
* Community Nursing or similar relevant post-registration experience
* Experience of multi-disciplinary and partnership working in acute and community settings
* Advanced understanding of clinical conditions and clinical experience in managing long-term conditions
* Experience of being part of a change management process demonstrating a positive attitude to change.
* Clinical Supervision experience
* Student mentorship/assessment skills and experience
Skills, Abilities and Knowledge
Essential
* Broad range of clinical skills
* An understanding of wider NHS and social care issues
* An understanding of intensive case management and systems for case finding
* Ability to influence and motivate staff at all levels
* Effective presentation skills
* Competent in use of IT hardware and software such as the Microsoft Office package
* Ability to prioritize and work to deadlines
Communication
Essential
* Demonstrates ability to adapt communication styles depending on audience including GPs, commissioners, patients, and carers
* Ability to use tact & diplomacy in communicating potentially difficult messages
* Excellent observational & reporting skills
* Able to concentrate when undertaking patient care & inputting data/patient records
* Excellent interpersonal skills when working with both patients, carers, colleagues, and fellow professionals
* Able to communicate effectively in written and verbal English Language
Personal and People Development
Essential
* Ability to work as part of a team
* Able to maintain a professional appearance
Other
Essential
* Must hold a full and valid driving license and have access to a vehicle
* Will be able to make own travel arrangements to patients' homes, clinics, base, and meetings etc., as required.
* Be able to kneel, bend & stoop, and work in cramped environments
* Be able to maneuver limbs of around 5-6 kg
* Be able to maneuver patients using handling aids
Employer details
Employer name
Norfolk Community Health and Care NHS Trust
Address
Norwich Community Hospital
Bowthorpe Road
Norwich
NR2 3TU
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