To undertake a comprehensive assessment of patients, including those with diverse or complex presentations/multi pathologies.
To work with the acute Multi-Disciplinary Team & Transfer of Care Hubs to promote an efficient, effective discharge from hospital to the patient’s own home.
To bring a holistic therapeutic approach to the multi-disciplinary team. Concentrating specifically on admission avoidance strategies and interventions.
To have a role in the responsibility for the management of patients care pathway through the CIS services
To be responsible for a designated caseload of patients, where you will implement and evaluate treatment plans, and coordinate interventions within Home First & Urgent Community Response.
To liaise with health, and adult social care, working in partnership with primary and secondary care, social prescribers, and other external agencies to ensure the delivery of a high-quality service, and facilitate effective discharge from the Home First Service.
To provide a specialist service to patients in their own home/usual residence
To communicate effectively with patients and carers and allied agencies to maximise discharge and recovery potential and to ensure understanding of condition
To be professionally and legally accountable for all aspects of own work, including the management of own patient caseload. To ensure a high level of care, and support more junior staff to do likewise.
Promote a holistic, supportive, and patient cantered service that facilitates an intervention approach to promote change, acceptance and promotes self-management aiming to optimises functional improvement
Work with Home First: supporting with triage, patient care pathway, and sharing knowledge related to the discharge to assess and admission avoidance strategies
Work with patients, carers and families, and other statutory health related services
Work autonomously and within the MDT team delivering individualised treatment interventions and management programmes
Be flexible in the approach to delivering treatment and advice, have skills to deliver a variety of treatment interventions
Have advanced communication skills that would include motivational and emotional support skills
Central and North West London NHS Trust expects all staff to act in a way which shows you understand our core values and are willing to put them into practice with service users, their friends, family, carers, and also other staff members.
As a member of the clinical team, we expect you to show COMPASSION , contribute to a caring and kind environment and recognise that what you do and say helps can make the lives of others better.
We expect you to RESPECT everyone and acknowledge and welcome people’s differences rather than ignore them or see them as problematic.
We expect you to EMPOWER others and continually try to provide information, resources and support to help others make their own decisions and meet their own needs.
We expect you to work in PARTNERSHIP and behave in a way that shows that you recognise that commissioners and users of our services are the people who generate and pay for our work.
The successful applicant may have contact with patients or service users. As an NHS Trust we strongly encourage and support vaccination as this remains the best way to protect yourself, your family, your colleagues and of course patients and service users when working on our healthcare settings.
To be professionally and legally accountable for all aspects of own work, including the management of own patient caseload. To ensure a high level of care, and support more junior staff to do likewise.
Promote a holistic, supportive, and patient cantered service that facilitates an intervention approach to promote change, acceptance and promotes self-management aiming to optimises functional improvement
Work with Home First: supporting with triage, patient care pathway, and sharing knowledge related to the discharge to assess and admission avoidance strategies
Work with patients, carers and families, and other statutory health related services
Work autonomously and within the MDT team delivering individualised treatment interventions and management programmes
Be flexible in the approach to delivering treatment and advice, have skills to deliver a variety of treatment interventions
Have advanced communication skills that would include motivational and emotional support skills
To use advanced clinical reasoning skills and assessment techniques to analyse and provide an accurate diagnosis of their condition.
Manage a patient through the entirety of their care episode in relation to Home First assessment, symptom management, support and discharge.
Where appropriate to work collaboratively with primary and secondary health care services, third sector services and social prescribing, education and social services, to ensure the delivery of a seamless and high-quality service.
Have a broad skill set which can include advanced skills in delivering therapy intervention in order to provide a 2-hour urgent response for patients in a crisis.
Manage severe complex, house bound patients. The CIS Home First service offers a domiciliary service to severely affected individuals; this requires collaborative working with social services and other attending care agencies.
Be able to recognise the signs and symptoms of a deteriorating patient, having the skills to escalate accordingly.
Be an advocate for the patient.
Knowledge of where to sign-post patients for support, e.g. local or national support groups
To be responsible for a caseload and work without direct supervision, and provide peer support for members of the MDT
To ensure patient care and planned interventions are supported by available evidence base and experiential knowledge and are in accordance with Code of Professional conduct.
To keep up to date and monitor literature related to Discharge to Assess and Crisis Response.
To carryout risk assessment in line with Trust/National Protocol

Please refer the Job description for details