Job Overview
The role involves assessing and coordinating patients' care by collaborating with health, social care professionals, and the voluntary sector. It requires understanding the needs of frail patients and ensuring high-quality outcomes that support individuals, families, and carers.
Main duties of the job
Key Responsibilities (Clinical)
1. Coordinate care pathways for vulnerable older people, managing a varied caseload across agencies.
2. Engage regularly with GP surgeries and PCNs to support proactive identification of at-risk patients.
3. Participate in monthly GP/PCN MDT meetings, highlighting patients at risk of crisis and planning early interventions.
4. Track patients admitted to hospital, build links with secondary care, and monitor patients post-discharge.
5. Assess and visit patients at home within 2 days of hospital discharge, conducting holistic assessments.
6. Ensure patients have individual care plans with focused goals.
7. Support the use of frailty and risk assessment tools across teams.
8. Communicate effectively using verbal and non-verbal tools with patients, carers, families, and colleagues.
Working for our organisation
We value staff who share our Trust values of Care, Learn, and Empower. Benefits include Season Ticket Loans, NHS discounts, training opportunities, flexible leave schemes, bank shifts, salary sacrifice schemes, and flexible working options from day one.
Our Trust supports flexible working; ask your manager about options. You may also join our Staff Bank, which hires staff for shifts at our hospitals and community settings. Existing staff are automatically enrolled, with no obligation to work extra shifts.
Note: Staff at risk will have priority for alternative employment. If a post is deemed suitable as an alternative, it may be withdrawn from NHS Jobs.
Use of Artificial Intelligence (AI)
Applicants should write their applications personally. Use of AI may lead to rejection. Support is available for those with disabilities.
Professional References
Include references covering the last three years of employment. Personal or character references are not accepted. The cost of the DBS check will be deducted from your first salary.
Applications for Job Share are welcome.
Equal Opportunities Employer
We encourage applications from people with mental health experience, learning disabilities, and those with disabilities. Contact us for accessible application formats.
Vacancies may close early. Check your email regularly; if no response within three weeks post-closing, your application was unsuccessful.
We are committed to safeguarding children, young people, and vulnerable adults. All staff undergo safeguarding procedures.
Covid Vaccination
While not mandatory, vaccination is encouraged. Contact epunft.cv19hr@nhs.net for info or to book a vaccination.
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