Intermediate Care Team Role Overview
The Intermediate Care Team will deliver short-term nursing and therapy care to people in their place of residence, to prevent acute hospital admission by safely supporting people at home or to support hospital discharge. A care plan or rehabilitation programme will be agreed with the person based on their individual goals to maximise independence. The service will be delivered over 7 days and will receive all referrals from acute and community providers. Therapist nurses and AHP support workers will work closely with social care and voluntary sector partners to maximise the use of a blended model of care.
Responsibilities
* To work as a member of the multi-disciplinary Intermediate Care Team.
* To undertake holistic assessments, clinical diagnosis and treatment of patients who may require rehabilitation interventions to prevent acute hospital admissions and to support complex hospital discharges. These patients often have complex presentations.
* To work in conjunction with a wide range of clinical colleagues and specifically, primary care and community teams and Social Care professionals, leading and facilitating a patient or client focused, co-ordinated case management approach across primary and secondary care for people who are most vulnerable to, and at high risk of repeat admission to hospital.
* To participate in and influence efforts across health and social services to shape multi-disciplinary pathways designed to support patient choice, improve quality of life, promote self-management and assure early intervention through the proactive provision of care in or as close to the patients own home as possible.
* To work as an autonomous practitioner to undertake a significant clinical caseload, working without direct supervision. Access to an Occupational Therapy/Physiotherapy Team Lead is available within the service.
* To devise effective, personalised plans of care for each patient with specific therapeutic knowledge. Goals and objectives of interventions are established and negotiated, and where appropriate can be assessed through use of outcome measures/ objective markers.
CSH Surrey are part of the NHS and are Surrey's longest established NHS community services provider, so our employees get NHS pay and pensions, and also receive the Fringe High-Cost Allowance of 5%.
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