Overview
This role is offered on a fixed term/secondment basis for 6 months. The hours are 37.5 hours per week. Internal applicants who wish to be considered for a secondment opportunity should discuss with their line manager the suitability of a possible secondment.
The Complex Care at Home Matron/Clinical Case Manager assumes the role of an autonomous Clinical Practitioner, responsible for overseeing the care of their assigned patients. This entails triaging, planning, managing, and coordinating intricate care and treatment requirements within patients' homes. As a member of the Complex Care at Home Multidisciplinary Team, they proactively manage patients with long-term conditions and at risk of deterioration, including those with frailty. The Community Matron/Clinical Case Manager provides comprehensive and specialised support to patients, carers, and families, enabling them to lead fulfilling lives alongside their conditions. They employ motivational interviewing and health coaching to establish therapeutic relationships, thereby mitigating unplanned hospital admissions. This proactive strategy fosters improved health outcomes. The Community Matron/Clinical Case Manager works closely with primary and secondary care services, including Physical and Mental Health, as well as statutory and non-statutory agencies, enabling the development of personalised care plans and consistently advocating for the What matters to you? principle.
The post holder will mainly communicate face to face with patients in their own homes whilst undertaking assessments and will also undertake follow-up telephone calls and letters when required. There may be times when the post holder will have to adapt their communication style to the audience when patients have difficulty in understanding. The post holder will be highly skilled in communicating effectively and be able to deal appropriately with complex and sensitive information.
This role is not eligible for sponsorship as per the Governments UK VISA and Immigration Rules and Regulations. For more information please visit https://www.gov.uk/browse/visas-immigration/work-visas
They will work with other members of the team to organise workload and flexibly cover the service across the County. The post holder will primarily provide face-to-face care in patients\' homes, with follow-up telephone calls and letters when required.
Responsibilities
* Triage: Ensure patients meet the criteria for the service.
* Holistic Assessment: Conduct a comprehensive assessment within the patient\'s home environment.
* Risk Assessment: Evaluate patients\' safety needs to determine the most appropriate care setting, providing specialist advice and signposting or referring to other healthcare providers as needed.
* Medication Assessment and Review: Assess and review medication for therapeutic effectiveness, prescribing, and/or de-prescribing in accordance with evidence-based practice, national and local protocols, within the scope of practice and legislative framework. Collaborate with other prescribers (GPs, pharmacists, consultants, and specialists) to ensure continuity and safe prescribing practices.
* Case Management: Identify, prioritise, and implement case management plans to achieve health gains and maximise patient independence.
* Communication: Maintain effective and timely communication with patients, carers, and all relevant services and agencies (statutory and non-statutory).
* MDT Meetings: Attend, participate, and lead where appropriate weekly internal MDT meetings and external meetings as required.
* Supervision & Line Management: Provide clinical supervision to Health 7 Wellbeing Coordinator and, as a line manager, sign off expenses and annual leave according to Trust policy.
* Documentation & Collaboration: Ensure documentation is up to date and collaborate with primary and secondary care services to support patient care.
Qualifications and Requirements
The qualification, training & experience requirements for the role are underlined in the Job Description/Person Specification.
About the Organization
We have a skilled and dedicated workforce of over 5000 colleagues working in a diverse range of services over 55 sites and within peoples homes. We strive to enable a welcoming workplace culture that builds and celebrates civility, inclusivity and diversity, while providing a sense of belonging and trust.
The post holder will mainly communicate face to face with patients in their own homes and will undertake assessments, with follow-up calls as required. The role requires effective communication skills, especially when explaining complex information.
Additional Information
This role carries fixed term/secondment details and does not include UK visa sponsorship. For sponsorship information, visit https://www.gov.uk/browse/visas-immigration/work-visas.
The following are related roles and opportunities that may be of interest: Education Health and Care Plan Co-Ordinator, National Clinical Associate Practitioner Supervisor, etc. (non-exhaustive list).
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