Job overview
The core aim of the neuro navigator posts is to provide a seamless approach to patient’s requiring specialist rehabilitation. Through advice, signposting and monitoring and transition support to the patient, and the family the journey is more efficient, cost effective and patient centred.
Each Neuro Navigator would be place based and have detailed clinical and system knowledge of local and regional stroke, trauma and neuro rehab pathways.
A regional team approach is implemented to improve equity of access, facilitate a wider place and sector wide knowledge and team approach. This facilitates peer support and learning and urgent (brief) signposting/ advice cover.
Main duties of the job
1.Act as a link person for acute and community colleagues, rehabilitation units and GPs and the continuing healthcare team.
2. Provide feedback on the local and regional systems through working links with commissioners on a local and regional basis.
3. Provide an expert assessment of neuro rehabilitation need, providing a solid understanding of the clinical impact of stroke and acquired neurological conditions.
4.Provide an expert neuro rehabilitation opinion working in partnership with health and social care professionals.
5.Facilitate and support the referral process into the relevant rehabilitation pathway.
6.Monitor and support rehabilitation admissions, including supporting the teams with discharge planning.
7.Provide training as required to support best practice and knowledge within the system.
8.Support the identification and brokerage of spot purchase level 2 b neuro rehabilitation and /or alternative Level 1 provision. Liaising closely with ICB colleagues.
9.*Some neuro navigators may provide a case management approach to patients following admission to specialist rehabilitation who are placed within specialist nursing homes or who have ongoing therapy provision under continuing healthcare
1.*Some neuro navigators may provide a case management approach to patients following admission to specialist rehabilitation when in the community with support from the local authority. (* for local agreement)
Working for our organisation
Our mission is to make a positive difference to people's lives by improving the quality of life for all we serve. Our values are: We Care, We Respect, We are Inclusive – so we are looking for people who live and breathe these qualities when supporting service users and carers, and in their relationships with colleagues in the Trust and our partner organisations.
Detailed job description and main responsibilities
·To be an integral member of the *community rehabilitation team with responsibility for supporting patients with a X GP with complex neuro rehabilitation needs as they move from acute services through to in-patient services and into community services.
·To work in partnership with acute services, specialist neurological rehabilitation services, local rehabilitation and community services in identifying the most appropriate patient pathway utilising level 1, 2a, 2b and community provision.
·To signpost and support the referral process for specialist neuro rehabilitation admissions (level 1, 2b).
·Use clinical expertise and system knowledge to identify and recommend appropriate spot purchase neuro rehabilitation admissions as required. Providing brokerage and monitoring of the admission as appropriate.
·To demonstrate highly developed therapy skills, assisting and enabling staff to assess, plan, implement and evaluate care; integrating therapy interventions in community care packages, as well as assisting to identify if inpatient rehab as appropriate.
· To minimise unnecessary waits within the rehabilitation system, supporting acute teams and rehab providers to communicate up to date and relevant information.
·To provide expert advice and signposting to the local neuro rehabilitation system.
·To work directly with clients and other health care professionals in a facilitative and supportive role in issues surrounding therapy interventions.
·Working within varied and sometimes challenging socio-economic environments with clients and their families who may face complex social problems and who, as a group, come from culturally diverse background (some are unable to speak English).
·To support the teams to ensure timely discharge and avoid delayed transfers of care ensuring discharge planning is co-ordinated with local resources and local knowledge avoiding delays to planned discharge.
·To attend case conferences and review meetings at specialist neuro-rehabilitation units and spot purchase beds to support individual pathways through complex specialist rehabilitation.
·*Support acute and rehabilitation services in the completion of CHC and associated paperwork and support the transference over to CHC if required for long term placement.
·To ensure that the most appropriate placement is identified on discharge from rehabilitation providers.
·To support the discharge plan to placement/ home. Ensuring the transition of rehab goal achievement, care plans, therapeutic care requirements e.g. wheelchairs, specialist seating, communication aids, cognitive strategies into the new placements and specialist adaptive equipment.
Person specification
Education
Essential criteria
1. Recognised degree in Nursing/AHP
2. Advance training in Neurology
Desirable criteria
3. Masters
Experience
Essential criteria
4. Experience of working in the NHS setting with effectively administrative and data duties
5. Experience case managing people with complex neuro disability
6. Experience of neuro navigator role
Skills and abilities
Essential criteria
7. Excellent interpersonal skills, including observation, listening and empathy skills.
8. Negotiation and problem solving skills with data analysis.
9. Knowledge and understanding of how to improve and develop services
10. Excellent communication skills
11. Good IT skills/data collection
12. knowledge of Neuro conditions