Community Matron

at  Mersey Care NHS Foundation Trust

Join our Care Home Liaison Team in Knowsley as a Community Matron (Advanced Nurse Practitioner).
The post holder will be a highly skilled practitioner, with the ability to work autonomously, with experience in clinical examination/diagnostics. The Community Matron will be the named Clinical nurse lead for the Care Homes within the Primary Care Network.
The post holder will provide leadership and have managerial responsibilities for senior clinical nurses within the service and support the education and training scheduling for staff in care homes.
The ability to be able to travel between different sites is essential.
The post holder will be required to provide clinical case management to a group of patients who meet the Trust identified criteria, who have long term conditions and other complex medical and social problems. They will develop the clinical case management role and function across health and social care organisations. The primary function of the role is to maximise the patient’s health, clinically assess and treat patients in a defined group and reduce risks that contribute to ill health, thereby reducing unnecessary admissions to acute services, reducing demand on GP time and facilitating the delivery of efficient, effective, co-ordinated and timely high quality care to patients.
Mersey Care is one of the largest trusts providing physical health and mental health services in the North West, serving more than 1.4 million people across our region and are also commissioned for services that cover the North West, North Wales and the Midlands.
We offer specialist inpatient and community services that support physical and mental health and specialist inpatient mental health, learning disability, addiction and brain injury services. Mersey Care is one of only three trusts in the UK that offer high secure mental health facilities.
At the heart of all we do is our commitment to ‘perfect care’ – care that is safe, effective, positively experienced, timely, equitable and efficient. We support our staff to do the best job they can and work alongside service users, their families, and carers to design and develop future services together. We’re currently delivering a programme of organisational and service transformation to significantly improve the quality of the services we provide and safely reduce cost as we do so.
Flexible working requests will be considered for all roles
Maximise independence by supporting people with long term conditions and highly complex needs to remain in their own homes as appropriate, by utilising and commissioning available resources.
Undertake clinical assessment and diagnosis and provide treatment for patients within the defined group.
Link with existing services to facilitate early discharge from hospital and prevent re-admission.
Develop Partnerships and joint working within the local health and social care economy.
Work collaboratively across organisation boundaries to support the effective and co-ordinated provision of social care and health care services.

CLINICAL REQUIREMENTS:

Conduct a comprehensive health and social care assessment, utilising any current information in order to develop an individualised plan of care for patients within a defined group. This will include:
Review of health assessment including medical history
Physical examination
Assessment and review of medication
Prescribing in conjunction with management plans
Making referrals for diagnostic tests
Functional /cognitive assessment
Assessment of social care needs
Develop, monitor and manage the plan of care in collaboration with the primary health and social care team and others through:
Application of clinical knowledge about long term conditions
Analysis of symptoms and data
Identification of risk factors associated with exacerbation of patients condition
Recognition and management of early signs and symptoms of acute illness.
Involving patients and carers in the development of the care plan and ensuring that their views and abilities are reflected.
Documentation of progress and continuous reassessment
Referral and investigation
To be responsible for maintaining competence in clinical and diagnostic skills required to manage patients
Set up and actively participates in case review to evaluate the outcomes of care plans including social care needs
Co-ordinate care and treatment to avoid fragmentation, duplication and delay, in the least intensive setting appropriate to the patient’s needs by:
Prioritisation and co-ordination of multiple health and social care needs
Referrals to specialist services
Ensuring effective communication and sharing of appropriate information amongst professionals to avoid conflicting treatments.
Integration across health and social care (inc. voluntary sector and housing)
Identifying deficiencies in service provision and addressing these as appropriate (i.e. through commissioning services for individuals)
Understanding and working through entitlements to social care and necessary financial assessments
Be aware of and adhere to, the Professional bodies Standards for administration of Medicines Act 1992, and the Misuse of Drugs Act 1971.

LEADERSHIP REQUIREMENTS

Lead the process of identifying their caseload through interpretation of the information available on the health needs of the locality in which they are based and contribute to the collection of data to monitor outcomes measures for the caseload
Participate in the development of case management across the Trust
Provide clinical leadership and mentoring to those staff developing into a case management role
Make, implement and communicate changes to clinical practice as necessary in relation to case management
Challenge professional and organisational boundaries to ensure that the Case Management role is focused on meeting the needs of service users, thus promoting continuity of high quality patient centred health and social care.
Acts as an advocate and champion for patients in a variety of forums and professional groups and challenges attitudes and behaviour.
Act as a role model so that patients receive the most effective care possible through:
Encouraging optimum management of long term conditions to ensure that the patient is functioning at the most independent level possible
Acting in patients’ interests at all times
Contributing to the development of policy and services to reflect the needs of the patient caseload.

SERVICE DEVELOPMENT REQUIREMENTS

Encourage patient and carer participation in case management through:
The provision of information about disease prevention, progression and outcomes.
Ensuring that services are accessible to increase patient confidence
Empowering the patient to self-manage whenever possible.
Contribute to the development of role and service redesign in long term condition management.
To provide clinical leadership for the development of the urgent care agenda

ANALYTICAL AND INFORMATION REQUIREMENTS

The post holder will utilise data and data tools (including databases) to produce appropriate monitoring reports on both patient care and service outcomes and produce appropriate communication for patients

CLINICAL GOVERNANCE REQUIREMENTS

Participate in individual and group clinical supervision and action learning sets, and to take responsibility for developing own learning.
Participate in research and audit relating to long term conditions management.
Ensure systems are in place for on-going review and assessment of care provision and delivery.
Improve quality via Clinical Governance, and Clinical Supervision, by working closely with colleagues to address competency levels within the service.
Report any incidents through application of trust policies.
Participate in patient satisfaction reporting to improve patient care.

EDUCATION AND DEVELOPMENT

Promote formal and informal training to pre and post registration health and social care professionals in relation to integrated working and provide mentorship and teaching to others developing a case management function.
Participate in the induction of new staff.
Provide education, advice and support to health and social care staff, people with long term conditions and their carers; in both community and acute settings.
Maintain up to date knowledge and competence in line with professional and service requirements and demonstrate critical thinking, decision making and reflective skills to ensure own professional development.

COMMUNICATION/RELATIONSHIP REQUIREMENTS

Liaise with patients and carers, community and specialist nursing and other health professionals, GPs, acute colleagues, social care colleagues and the voluntary/charitable and non-NHS sector.

Manage the complex clinical and social care interventions of individuals within an identified patient group on an ongoing basis.
Undertake risk assessment in relation to individuals within the client group
Monitor and respond to the development of changing clinical and social situations with the identified patient group without recourse to others where possible
Ensure the safe management of care and service delivery
Line manage a defined team of staff; including performing appraisal, personal development reviews and the application of staff management procedures