To provide band 4 clinical navigator support for patients on suspected Lung Cancer Pathway
To provide Holistic Needs Assessment for Patients.
To work under supervision of the Specialist Nursing Team
Provide information and support for patients and their carers
Care Coordination is not one person's role, job or responsibility. It is the joining up of services, coordination, information and communication between care givers, treatment providers, those living with and beyond cancer and their families that creates a seamless experience of care (NHS Improvements, 2011).
The purpose of this role therefore is to complement the existing lung cancer nursing service to ensure the provision of safe, seamless, appropriate services, thus maximising the health and quality of life of the patient and carers and improving the quality and efficiency of health care delivery.
Walsall Healthcare NHS Trust is an integrated Trust and the only provider of NHS acute care in Walsall, serving a population of 284,300, providing inpatient and outpatient services at the Manor Hospital as well as a wide range of services in the community. Walsall Manor houses the full range of district general hospital services under one roof. The £170 million development was completed in 2010 and the continued upgrading of existing areas ensures the Trust now has a state-of-the-art Critical Care Unit, Neonatal Unit, Obstetric Theatre, and Integrated Assessment Unit facilities.
A new Urgent Emergency Care Centre was opened in March 2023. The two-storey development has significantly improved emergency care facilities and capacity and has provided almost 5,000 square metres of additional clinical space.
Coordination of care Under the guidance and supervision of a registered practitioner, coordinate care by providing a single point of access, including rapid re-entry into the system for those people identified as having urgent or specialist needs.
1. Triage incoming calls and initiate appropriate response according to assessment tools, protocols and individual pathways, liaising with the CNS as appropriate.
2. Provide basic telephone advice and refer on or signpost to other sources of support.
3. Make pre planned outbound telephone calls to patients to assess needs and monitor progress, liaising with the CNS and other members of the healthcare team as appropriate in order to initiate a proactive prevention approach
4. Coordinate the necessary assessments, appointments or investigations as identified in patients care plan.
5. Support the delivery of patient information to ensure all patients/carers receive appropriate verbal/written communications on a timely manner – this may include printing out information prescriptions, referring to the Cancer Information and Support Service, ensuring that patients receive the new patient information pack and understand its contents.
6. Document and monitor all aspects of care coordination and service delivery.
7. Act as the patient advocate and facilitator in order to resolve issues that may be perceived as barriers to care.
8. Coordinate the care for patients assessed by a registered practitioner as having noncomplex needs and support self-management programmes.
9. Contribute to holistic needs assessment and the development of a care plan for patients with non-complex needs and monitor and review care plan with the patient and carer.
10. Evaluate outcomes of care delivery with the registered practitioner.
11. Assist people to access appropriate information and support by sign posting to a range of support services and encourage self-management where appropriate.
12. With collaboration from the Lung Cancer Nurse Specialists continue to advise patients on individual self-management principles and provide consistent planned follow up to reinforce and further promote this information.
Communication
1. Support the delivery of education for patients and carers
2. Encourage and support active healthy lifestyle choices.
3. Coach patients and carers to understand the signs, symptoms or situations to be aware of that would indicate concern.
4. Inform patients and carers on how to make contact when they feel their condition or needs have changed, including what to do out of hours.
5. Ensure that patients and carers are aware that they are interacting with a Macmillan professional and are made aware of the full range of resources and services available through Macmillan.
6. Actively engage with Macmillan Cancer Support to contribute expertise and experience to support the Macmillan Corporate Strategy.
7. Effectively utilise a computer and various software applications to enter and maintain patient data, communicate with the multidisciplinary team and complete other IT tasks as required by the post.
8. Discuss support options with patients and carers with sensitivity and ensure that the specialist nurse is kept informed of outcomes.
9. Promote patient/user involvement relating to the provision of cancer care.