Complex Clinical Case Manager (Discharge to Assess)
Are you a passionate andexperienced Band 7 Nurse seeking a new challenge? Are you committed to ensuring our patientsreceive exceptional care and support in the community? If so, we would like to invite you to join our Black CountryWolverhampton team, where youll play a pivotal role in the Discharge to Assesspathway within the All-Age Continuing Care service.
You will work alongsidea multidisciplinary team of skilled health and social care practitioners tosupport seamless patient flow across acute and community settings ensuringpatients receive the right care, at the right time, in the right place and preventunnecessary hospital stays and readmissions.
We invite applicationsfrom registered nurses interested in contributing to a dynamic,multi-disciplinary team and supporting patients as they transition fromhospital to home. By joining our team, you will play a vital role in enhancingpatient outcomes and making a positive impact within our community.
Main duties of the job
Key Responsibilities:
* Provide ContinuingHealthcare expertise as part of the Discharge to Assess pathway.
* Support triage and carenavigation, helping patients transition safely and efficiently from hospital tocommunity or home-based care.
* Coordinate high-qualitypatient care, working closely with colleagues across health and social care.
* Participate instakeholder engagement, developing and maintaining good collaborativeworking relationships
* Undertake healthcareassessments and develop robust care and support plans in collaboration withother healthcare professionals.
* Offer clinical guidanceto ensure best practices and optimal patient outcomes.
* Engage in ongoingprofessional development and embrace learning opportunities.
Requirements:
* Registered Nurse with avalid NMC registration.
* Experience in a similarrole, preferably within integrated or community-based care settings.
* Ability to work aflexible 7-day rota, ensuring comprehensive and responsive support for patientsand colleagues.
* Demonstrated leadershipand management skills, with a commitment to high standards of care.
* Excellent communicationand interpersonal abilities, with a collaborative approach to teamworking.
* Dedication to deliveringhigh-quality care and improving patient experience and outcomes.
About us
TheBlack Country Integrated Care Board (ICB) is a statutory NHS organisationresponsible for developing a plan for meeting the health needs of 1.26 millionpeople in the Black Country. We managethe NHS budget for Dudley, Sandwell, Walsall and Wolverhampton and areresponsible for planning and buying Primary Medical Services (GPs), dental,optometry and pharmacy services.
Weare part of the Black Country Integrated Care System (ICS), known as HealthierFutures, which is a partnership of organisations working together to bringhealth and social care services closer together for the good of ourcommunities.
TheICB has five core values that underpin the way we work and help to guide ouractions and the decisions we make for local people and communities. These arecompassion, inclusivity, integrity, fairness and trust.
Ourorganisation is committed to creating the best place to work and believe inpromoting and enhancing equality, diversity and inclusion. We encourageapplications from all areas of the community who meet the criteria for therole, regardless of age, gender, disability, race, religion or sexualorientation.
Weare also a bronze award holder under the Defence Employer Recognition Scheme(ERS) which recognises our commitment and support from UK employers for defencepersonnel.
Note: the ICB is unable toprovide sponsorship to enable an individual to have the right to work in theUK, due to the size of the organisation.
Job responsibilities
* The post holder willbe required to provide a high-quality resource of professional advice, guidanceand expertise to members of the Individual Care Team, ICB and wider health andsocial care economy
* Autonomously manage acase load of individuals with highly complex health needs providing significantclinical guidance to providers.
* Ensure that allassessments are holistic in nature and utilise The National Framework for NHSContinuing Health Care.
* To have an expertlevel of knowledge regards The National Framework and its application inpractice. To be able to impart this knowledge to a variety of audiences.
* To provide complexand sensitive information to patients, relatives/ representatives and oftenwork in potentially hostile environments; relaying difficult decisionsregarding care provision and managing patient and family expectations.
* Provide continuity ofcare throughout the period of care and support. This will encompass closeworking with health and social care professionals and care providers.
* Attend all meetingsrelated the patient which may impact on the care provision and costs to meetidentified needs
* Liaise with multipleprofessionals involved in the patients care to ensure that a comprehensiveunderstanding of all identified needs is available. Ensuring that each patienthas a care plan that addresses all their identified needs and can be used to assistassessors when completing CHC assessments/reviews.
* Present comprehensivewritten reports to ICB Eligibility Panel following any reviews completed oncepatients are in receipt of agreed care provision that identify a change in thelevel of care required. This includes being able to demonstrate improvementsthat may result in a reduction of care provided or a change the patientseligibility for NHS CHC.
* To be responsible fornegotiating care package costs and the monitoring of packages offully funded care which are in excess of £1000 per week. To be responsible forensuring these care packages are reviewed to an agreed time scale, identifiedby the Head of Service and that these are recorded on the ICB database.
* Identify and processany safeguarding and quality of care issues and take appropriate actionto ensure that peoples welfare is protected and that the quality andstandard of services provided are at a level that is in line with ICB requiredstandards. Close liaison with the ICB Quality Team is necessary to ensure ICBfunded individuals are in receipt of high quality, safe care.
* Ensure MentalCapacity Act is considered and ensure relevant processes are followed eg. BestInterests, DOLs
* Develop and maintaineffective working relationships with clinicians, general practitioners andproviders in order to ensure continuity of care and address patient needs.
* Provide a high-qualityresource of professional advice, guidance and expertise to the ICB and partneragencies in addressing the needs of individuals with complex healthneeds.
* Liaising with avariety of providers and arranging assessment of patients in order that themost appropriate placement/provider is identified.
* Provide informationand support to the senior managers when considering the most appropriateprovider to address a patients identified needs and to act autonomously whenrequired to agree care packages in excess of the usual ICB cost.
* To maintain a formalrecord of all cases and ensure that all relevant clinical information isavailable and updated regularly, both electronically and in patient files.
* Support the Head ofCHC in working with partner agencies and other stakeholders in developing thelocal market for services to ensure that it reflects the requirements ofindividuals and is able to meet current and future needs
* To call and chairmulti-disciplinary meetings, including case conferences and discharge meetingsto ensure continuity of care across agencies; thus improving patient and familyexperience.
* Deputise for the LeadNurse as required
* Provide data in orderthat the ICB can continuously monitor care delivery and identify howperformance of providers can be improved. Working closely with colleagues inthe ICB Quality Team to assure the quality of care received by NHS fundedindividuals.
* To have budgetarymonitoring responsibilities and to ensure that the Head of Service is informedof any identified budget pressures or financial risks that may impact on theoverall service budget. The post holder will need to demonstrate both qualityof care and value for money in all placements.
* To develop policiesand procedures, as requested, which will support the overall delivery of NHSFunded Care within the ICB.
* To contribute to anddeliver training on CHC and FNC to a variety of audiences particularly inhealth and social care.
* To provideprofessional support and mentoring to the nurse assessors within the team andprovide additional support and training as required by the Lead Nurse.
* To work within theNMC Code/Professional Code** and to meet requirements for revalidation.
* To undertake andcomply with all mandatory training.
Person Specification
Experience
* Significant experience gained over a number of years in a complex, multi-disciplinary environment
* Extensive experience of case management with service users who have complex health needs
* A clear knowledge and understanding of The National Framework for NHS Continuing Health Care and its application in practice
* An understanding of the Mental Capacity Act 2005 and its application
* An understanding of commissioning for complex health needs in the context of NHS Continuing Healthcare
* Experience of monitoring a budget and understanding of financial systems and processes
Personal Qualities
* Self-motivated and enthusiastic
* Adaptability, flexibility to work and ability to cope with uncertainty and change
* Works well with others, is positive and helpful, listens, involves, respects and learns from the contribution of others
* Consistently looks to improve what they do, look for successful tried and tested ways of working, and also seeks out innovation
* Actively develops themselves and supports others to do the same
* Understanding of and commitment to equality of opportunity and good working relationships
* Professional, calm and efficient manner
Skills and Knowledge
* High level of working knowledge of the relevant legislation and theories underpinning the provision of services to the relevant client group
* Demonstrable experience and knowledge of current key policies and priorities within the NHS, especially within Clinical commissioning Groups
* A clear knowledge and understanding of service provision available locally, regionally and nationally for the client group
* Understanding of relevant current NHS and social care market mechanisms
* Good working knowledge of adult safeguarding
* Awareness of Data Protection and confidentiality issues
* Working knowledge of Microsoft Office with standard keyboard skills
* Effective interpersonal and negotiation skills enabling effective communication with clients, other professionals, colleagues, partner agencies, providers and carers.
* Excellent written and verbal communication including providing and receiving complex, sensitive or contentious information
* Ability to prioritise and to work effectively on own initiative
* Ability to work in hostile environments and deal with conflict on a regular basis
* Understanding of the commissioning/ procurement process for adults continuing health care packages
Qualifications
* Relevant degree/professional qualification in Nursing*** (local areas may differ/could be Social Work))
* Evidence of continuous professional development
* Educated to degree level or equivalent level of experience of working at a senior level in a specialist area.
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
#J-18808-Ljbffr