Community Matron

Key Areas of Responsibility To assess and provide advanced level interventions for patients with long termconditions to achieve quality of life and independence where possible. To work within the integrated team to facilitate early discharge from hospital. To work within the integrated team to prevent unnecessary admission to hospital. To work with all health care professionals, and statutory/non-statutory agencies toprovide a seamless, integrated service to our service users. To support patients in coordinating their personal health plans. To assess patients for assistive technology where appropriate. To refer on to social care support where appropriate. To support and manage band 6 Case Managers and band 4 Assistant Practitioners As part of transformation you will be required to Work when needed in the hub Engage with mobile working Engage with referral to discharge standard processes To be aware of the demand and capacity model which will reflect workload needs at anygiven time. Main Responsibilities Facilitate and develop a service providing complex case management. Track patients entering hospital or nursing home step-up beds and ensure that they aredischarged appropriately into the care of nurses and therapists of the integrated team. Working closely with GPs and the acute hospital and support service issues that mayneed resolving to ensure timely discharge. Proactively find patients who are very high intensity users of primary and secondaryhealthcare and/or are at high risk of unplanned admission to hospital. Educate and support the members of the multi-disciplinary teams to intensively casemanage these patients. Intensively manage their own caseload of patients with highly complex and unstablehealth needs. Independently manage the caseload by maintaining a consistent through put of patients. This should be achieved by - ensuring patients are discharged in a timely manner;promoting patient independence in managing their own health conditions; encouragingself-care and condition self-management; sign posting to other appropriate services; andby utilising strategies of health promotion and health coaching. Develop systems and processes to support intensive case management within the multidisciplinary team and with partners across the health system. Work with and refer appropriately to other agencies to enable identified patients to beintensively managed in a pro-active way with the aim of preventing hospital admission,supporting early discharge and reduce GP contact. Accountable for the intensive case management and where appropriate intervention of adefined patient caseload. Actively work with GPs and other agencies, and with appropriate informationtechnology, such as PARR ++, to case find patients. Be a champion for people with long term conditions. To provide clinical supervision for other staff. To clinically support the Norwich locality community teams at times of high/increaseddemand. Clinical Practice Using expert knowledge, advanced clinical and autonomous decision making skills,intensively case manage patients with highly complex and unstable health needs. Comprehensively assess, review and evaluate the needs of both patients and theircarers to improve their physical and psychological well being whilst reducing acuteexacerbation of underlying conditions and need for hospitalisation. Work in partnership with patients, carers, GPs, consultants, other health professionalsand social care as appropriate, to instigate diagnostic testing and therapeutic treatmentsto ascertain diagnosis, and implement proactive treatment and care plans. Use prescribing skills and knowledge of medicines to minimise the risk andcomplications associated with medication and polypharmacy. Maintain contact with patients who are admitted to hospital, ensuring the team providinginpatient care have the most up-to-date and relevant information and help facilitatedischarge as soon as the acute treatment phase is complete. Work with the multidisciplinary team in the development, implementation and evaluationof policies, protocols and guidelines. Provide clinical nurse leadership and support to other staff, enabling their own ongoingprofessional development and understanding of service provided. Develop care plans with patients involving others e.g. carers, advocates etc., to ensurebest outcomes for patients, focusing on their ability to function and their quality of life. Communicate complex patient information effectively to ensure collaborative working. Promote people equality, diversity and rights. Challenge professional and organisational boundaries, identifying areas of skill/knowledge development and applies these to practices to provide continuity and highquality patient centered health care. Actively assess patient for the use of assistive technology as a means to empowerpatients to take more control over their long term conditions, and implement whereappropriate. Leadership Establish clinical credibility within the multi-disciplinary team and act as a role model for clinical excellence. Work collaboratively with other case managers and other members of the multidisciplinary team to lead developments in professional practice and to support multidisciplinary working around the needs of very high intensity users and those at high riskof hospital admission. Use effective communication, negotiating and influencing skills to introduce newsystems of working to improve the pathway of patients who are very high intensity usersof health care and/or at high risk of hospital admission. Provide high quality reports and data on clinical activity. Encourage and support innovation, sharing of expertise and new ways of working withinthe multi-disciplinary team to meet the needs of patients.Education. Champion the role and value of case finding an intensive case management at all level of the organisation and across all professional groups Continually audit and evaluate the quality and effectiveness of clinical practice withinintensive case management, selecting and applying a wide range of valid and reliableapproaches and methods that are appropriate to the need and context. Contribute to the wider development of practice by participating in research, audit, localand national presentations, networks and publication as appropriate. Develop, implement and evaluate educational programmes for workers in primary andcommunity services to provide the necessary knowledge and skills for effective casemanagement of patients with long term conditions and at high risk of hospital admission. Educate and empower patients and carers to identify early signs of change in conditionand provide them with the necessary knowledge and skills to gain independence andmake informed choices to safely manage their condition.

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