Job overview
The ICCN will work closely with GP’s / DNs / Rapids / Social Care / Mental Health Services and acute hospitals to proactively case find and identify patients (aged 18+) with high-risk complex needs. They will provide a proactive, holistic approach to managing patients with long-term medical conditions that is centred on primary / community care and the prevention of avoidable hospital admissions.
The focus will be on providing comprehensive assessments, individualised care plans and coordination for complex patients in their usual place of residence including care homes. The ICCN will enable the patient, carers/care home staff and families to understand their disease or condition, how to recognise early symptoms and proactively coordinate and manage their care decisions. The ICCN will work as part of a multi- disciplinary neighbourhood team and will develop care plans for the patients on the Complex Care (Multi-disciplinary Meeting (MDM) and Long term conditions ( LTC) )caseload. With support from the multi-disciplinary team (MDT), the ICCM’s will attend once or twice weekly huddles with the MDT / MDMs to discuss patients on their caseload and formulate care plans. Where appropriate, referrals will be made to key stakeholders such as other community services e.g. district nurses, geriatrician, social services, mental health and third sector.
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Main duties of the job
The ICCN will work closely with GP’s / DNs / Rapids / Social Care / Mental Health Services and acute hospitals to proactively case find and identify patients (aged 18+) with high-risk complex needs. They will provide a proactive, holistic approach to managing patients with long-term medical conditions that is centred on primary / community care and the prevention of avoidable hospital admissions.
The focus will be on providing comprehensive assessments, individualised care plans and coordination for complex patients in their usual place of residence including care homes. The ICCN will enable the patient, carers/care home staff and families to understand their disease or condition, how to recognise early symptoms and proactively coordinate and manage their care decisions. The ICCN will work as part of a multi- disciplinary neighbourhood team and will develop care plans for the patients on the Complex Care (Multi-disciplinary Meeting (MDM) and Long term conditions ( LTC) )caseload. With support from the multi-disciplinary team (MDT), the ICCM’s will attend once or twice weekly huddles with the MDT / MDMs to discuss patients on their caseload and formulate care plans. Where appropriate, referrals will be made to key stakeholders such as other community services e.g. district nurses, geriatrician, social services, mental health and third sector.
Working for our organisation
CNWL is recognised locally, nationally and internationally for providing integrated high quality, innovative healthcare. Our track record in recruiting only the best people is well known, and our experts are frequently called upon to contribute to national health strategy and policy, and many models of our care have been adapted for use in other countries.
Camden is a vibrant home to some of London’s most visited tourist attractions: the markets, streets and shops that have grown around Camden Lock and its associated music venues. Camden as a Borough is diverse, containing Hampstead Heath and its famous swimming ponds, Holborn and parts of the West End, as well as a very colourful culture, ethnic makeup and a very wide socio-economic make up.
Detailed job description and main responsibilities
The ICCN will work closely with GP’s / DNs / Rapids / Social Care / Mental Health Services and acute hospitals to proactively case find and identify patients (aged 18+) with high-risk complex needs. They will provide a proactive, holistic approach to managing patients with long-term medical conditions that is centred on primary / community care and the prevention of avoidable hospital admissions.
The focus will be on providing comprehensive assessments, individualised care plans and coordination for complex patients in their usual place of residence including care homes. The ICCN will enable the patient, carers/care home staff and families to understand their disease or condition, how to recognise early symptoms and proactively coordinate and manage their care decisions. The ICCN will work as part of a multi- disciplinary neighbourhood team and will develop care plans for the patients on the Complex Care (Multi-disciplinary Meeting (MDM) and Long term conditions ( LTC) )caseload. With support from the multi-disciplinary team (MDT), the ICCM’s will attend once or twice weekly huddles with the MDT / MDMs to discuss patients on their caseload and formulate care plans. Where appropriate, referrals will be made to key stakeholders such as other community services e.g. district nurses, geriatrician, social services, mental health and third sector.
The distance nurses travel each day is considerable and the ICCN use public transport, trust pool cars or their own car to carry out home visits. The ICCN works autonomously to provide a full range of services predominantly to house bound patients including residential and nursing homes and will be skilled in carrying out Holistic assessments.
The role also involves senior clinical and some managerial leadership through attending key meetings as specialist clinicians and providing clinical/ managerial supervision for junior staff such as Community Nurses, Care Coordinators, Healthcare Assistants and Student Nurses and/or other staff working with the team.
The post holder will work in team of five ICCN’s one of whom has a specialist mental health remit. Each ICCN will be aligned to working in a specific neighbourhood bringing specialist community nursing skills to the MDT The post holder will be responsible for line management and supervision of the peer support worker role, championing the service and promoting peer support and recovery as a key role within the trust. Liaising with Peer Support network across the trust and ensuring relationships are maintained alongside service development.
Vaccination
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.
1. Due to the high response levels we receive for some vacancies, we may expire any of them prior to the advertised closing date and advise you to submit your application as soon as possible.
2. Applications from job seekers who require sponsorship to work in the UK are welcome and will be considered alongside all other applications. Before submitting your application and to avoid disappointment please check that you are eligible under the
3. Our Agenda for Change employment contracts are subject to a contractual 13 week probationary period.