Community Matron (Annex 21)

Job responsibilities

KEY DUTIES

• Maximise independence by supporting people with long term conditions and highly complex needs to remain in their own homes as appropriate, by utilising and commissioning available resources
• Undertake clinical assessment and diagnosis and provide treatment for patients within the defined group.
• Link with existing services to facilitate early discharge from hospital and prevent re-admission.
• Develop Partnerships and joint working within the local health and social care economy.
• Work collaboratively across organisation boundaries to support the effective and co-ordinated provision of social care and health care services.
• Be aware of and adhere to, the Professional bodies Standards for administration of Medicines Act 1992, and the Misuse of Drugs Act 1971.
• Challenge professional and organisational boundaries to ensure that the Case Management role is focused on meeting the needs of service users, thus promoting continuity of high quality patient centred health and social care.
• Acts as an advocate and champion for patients in a variety of forums and professional groups and challenges attitudes and behaviour.
• Act as a role model so that patients receive the most effective care possible through:
• Encouraging optimum management of long term conditions to ensure that the patient is functioning at the most independent level possible.
• Acting in patients interests at all times.
• Make, implement and communicate changes to clinical practice as necessary in relation to case management

CLINICAL & PROFESSIONAL RESPONSIBILITIES

Conduct a comprehensive health and social care assessment, utilising any current information in order to develop an individualised plan of care for patients within a defined group. This will include:

• Review of health assessment including medical history.
• Physical examination.
• Assessment and review of medication.
• Prescribing in conjunction with management plans.
• Making referrals for diagnostic tests.
• Functional /cognitive assessment.
• Assessment of social care need

Develop, monitor and manage the plan of care in collaboration with the primary health and social care team and others through:

• Application of clinical knowledge about long term conditions.
• Analysis of symptoms and data.
• Identification of risk factors associated with exacerbation of patients condition.
• Recognition and management of early signs and symptoms of acute illness.
• Involving patients and carers in the development of the care plan and ensuring that their views and abilities are reflected.
• Documentation of progress and continuous reassessment
• Referral and investigation.
• To be responsible for maintaining competence in clinical and diagnostic skills required to manage patients.
• Set up and actively participates in case review to evaluate the outcomes of care plans including social care needs.
• Co-ordinate care and treatment to avoid fragmentation, duplication and delay, in the least intensive setting appropriate to the patients needs by:
• Prioritisation and co-ordination of multiple health and social care needs.
• Referrals to specialist services.
• Ensuring effective communication and sharing of appropriate. information amongst professionals to avoid conflicting treatments.
• Integration across health and social care (including voluntary sector and housing).
• Identifying deficiencies in service provision and addressing these as appropriate (i.e. through commissioning services for individuals).
• Understanding and working through entitlements to social care and necessary financial assessments.
• Lead the process of identifying their caseload through interpretation of the information available on the health needs of the locality in which they are based.
• Participate in the development of case management across the Trust.
• Provide clinical leadership and mentoring to those staff developing into a case management role.
• Contributing to the development of policy and services to reflect the needs of the patient caseload.
• Liaise with patients and carers, community and specialist nursing and other health professional, GPs, acute colleagues, social care colleagues and the voluntary/charitable and non-NHS sector

TEACHING & TRAINING RESPONSIBILITIES

• Promote formal and informal training to pre and post registration health and social care professionals in relation to integrated working and long term conditions and provide mentorship and teaching to others developing a case management function.
• Participate in the induction of new staff.
• Provide ...