PCN Community Matron

at  Firs House Surgery

Job Purpose To co-ordinate care provision through a case management approach for a defined high risk patient group with complex long-term conditions, such as COPD, diabetes, and CHD, with the aim to prevent hospital admissions and facilitate timely discharge. To provide the highest standard of clinical care by using advanced skills and expert knowledge to holistically assess needs and instigate and provide clinical treatments based on evidence-based practice. To participate in the delivery of educational programmes to patients, carers and health and social care workers that promotes self-care principles. To develop and promote robust multidisciplinary working across the wider Health and Social care sectors to ensure integrated service and support networks for patients.
To monitor the quality-of-care provision and to identify and promote areas for service development. To be the named Community Matron for a Primary Care Network (PCN), providing support and care coordination for the wider health team within the network. To work proactively with District Nursing colleagues and providing links across community nursing. To provide clinical leadership and support to end of life pathways, including the Urgent Care Planning framework KEY WORKING RELATIONSHIPS To work in partnership with community health, social care and third sector organisations To work in partnership with acute Trusts To work as a member of a Primary Care Network Main Duties and Responsibilities CLINICAL DUTIES To use advanced skills and expert knowledge to carry out a thorough assessment and history taking, including a systematic physical examination, in order to develop a comprehensive care plan.
To initiate, and provide, advanced clinical / therapeutic care treatments, in partnership with other providers, based on best possible evidence that will improve health outcomes. To use advanced clinical skills and expert knowledge to proactively identify subtle changes in a patients condition as early as possible and to manage these in a manner that optimises well-being. To take overall responsibility for coordinating the care, treatment and complex health funded packages of care for case managed patients in a variety of settings. This includes planning, developing, implementing, monitoring, and reviewing specialised programmes of health interventions for case managed patients.
To work within the principles of the Single Assessment Process. To maintain responsibility if a patient is admitted to an in-patient facility. This includes actively accessing the acute sector to provide base line health data to appropriately the receiving team and initiating early discharge for case managed patients. To appropriately refer patients for a range of physical and functional tests and assessments, in order to inform decision making and care pathway development.
To apply advanced pharmacological knowledge (non-medical prescribing) and undertake medication reviews, ensuring that duties in relation to medicines management meet required professional and the Trust standards. To be alert to the needs of vulnerable adults, identifying the risks of possible harm and taking appropriate action as required in accordance with Safeguarding Adult Guidance. To take a clinical leadership role in end-of-life pathways COMMUNICATION To communicate effectively at all levels, to a variety of health and social care professionals, users and carers, including difficult matters and all/difficult situations. To work in partnership with the District Nursing teams liaising on a regular basis to identify patients who would benefit from case management, accepting and referring patients as their health conditions change, and sharing in the nursing care programmes required for case managed patients.
To work in partnership with the patient, acting as the patients advocate, facilitating the patients own choices with regard to care, including planning advanced directives at end of life, whilst promoting independence and self-care and supported by the Best Interest process. To work collaboratively, and in partnership, with district nurses, GP and practice staff within the Primary Care Networks, to also include rehabilitation teams, clinical nurse specialists, the Community Independence Service, pharmacists, third sectors and social services to ascertain diagnosis and care programmes. MANAGEMENT AND LEADERSHIP To be a change agent actively facilitating changes in practice, including the challenging of professional and organisational boundaries, which will improve clinical outcomes, and meet the needs of patients and carers. To constantly champion the principles of self-care and patient empowerment.
To participate in the development, implementation, and evaluation of policies, guidelines and integrated care pathways, and service re-designs for long term conditions management. To proactively seek out and identify patients who would benefit from case management through regular communication with social services, hospital wards/ discharge teams, GPs and District nurses. To provide Clinical Supervision on a regular basis to designated staff members. To ensure the effective and efficient use of available resources.
To be goal and outcome orientated whilst maintaining a high level of performance. To actively participate in Team, Locality and other relevant meetings. To monitor standards and performance of the service, in line with clinical governance objectives. To maintain accurate and contemporaneous computerised and paper records, including statistical returns, as required PROFESSIONALISM & CLINICAL GOVERNANCE To be aware of, and act in accordance with, Clinical Guidelines and Policies, and the professional Code of Conduct.
To participate in the development, implementation and audit of Clinical Guidelines and Policies. To be aware of and act in accordance with Operational Policies. To carry out risk assessments on work practices. To participate in receiving regular Clinical Supervision.
To maintain appropriate and up to date knowledge and skills and undertake educational activities in accordance with personal and service needs within a framework of a Personal Development Plan. TEACHING AND TRAINING To attend appropriate education and training programmes in order to develop enhanced clinical skills and knowledge. To work with the integrated team to develop, implement and evaluate teaching programmes for patients and their carers, that provide necessary knowledge and skills for: self care and independence; safe self-management of their circumstances; planning for unavoidable progression in their conditions and effectively accessing health and social care. To identify learning and development needs of health and social care professionals and to participate in the creation and delivery of educational programmes in relation to managing long term conditions.
To participate in the induction, training, mentoring, and support of health care professionals and students, support staff and others as required. RESEARCH To participate in and lead on clinical and organisational audit activities related to the service. To continually evaluate the quality and effectiveness of the practice of self and others. To evaluate outcomes for patients in collaboration with other health and social care colleagues

Please refer the Job description for details