Overview
To be responsible and accountable for assessing, planning, implementing and evaluating patient care, demonstrating evidence based/best practice. To adhere to Walsall Healthcare NHS Trust policies, procedures and protocols in order to promote the quality of the patient experience in the community, ensuring the highest standard.
To provide professional support and mentoring to individual staff members and community place based teams, initiating continued professional development to help improve the care and management of palliative and end of life patients. To maintain effective channels of communication with the wider multi-professional team, to ensure co-ordinated patient care. To support implementation of the integrated care model within Walsall Healthcare Trust and work in partnership with key organisations, promoting patient care in the right place at the right time. To work as part of an integrated Community nursing team with a focus on case management for the frail elderly in their own home.
Using risk stratification identify patients who are vulnerable of hospital admission and implement a case management approach to maintain effective care and treatment in care environment. Work in partnership with home care staff, managers, Primary care, patients, relatives and the wider health and social care team to maintain high quality care, prevent avoidable patient harms, prevent avoidable hospital admission and reduce length of stay if acute intervention is required.
Responsibilities
* Provide evidence based high quality palliative and end of life care to patients with life limiting illnesses and support for their families.
* Deliver advanced skills and expert knowledge to assess the physical and psycho-social needs of a defined client group with complex long term conditions, instigating therapeutic treatments, including extended and supplementary prescribing, based on best available evidence to improve health outcomes.
* Deliver advanced skills to identify subtle and unpredictable changes in condition and make comprehensive and focused assessments.
* Work in partnership with GPs, consultants in Secondary care, and Integrated community nursing teams to ascertain diagnosis, develop care plans, interpret highly complex factors and situations, and initiate follow up for people who are frail and elderly.
* Negotiate and agree with patients, carers and other care professionals individual roles and responsibilities with regard to actions to be taken and outcomes to be achieved, referring on to other services or professionals as appropriate.
* Challenge professional and organisational boundaries, identifying areas for skill/knowledge development and apply these to practices to provide continuity and high quality patient centred health care.
This advert closes on Tuesday 7 Oct 2025.
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