Community Matron

Duties and Responsibilities 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 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. Clinical Requirements: 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 needs 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 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 N.B. for 8 & 9 please see note below Sets 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 (inc. voluntary sector and housing) Identifying deficiencies in service provision and addressing these as appropriate (ie through commissioning services for individuals) Understanding and working through entitlements to social care and necessary financial assessments ***8 & 9 Elements in these sections are existing care manager skills, i.e. District Nurse Team Leaders/ SPQ/level 7 and overlap with current Continuing Care practice*** Be aware of and adhere to, the Professional bodies Standards for administration of Medicines Act 1992, and the Misuse of Drugs Act 1971. Leadership Requirements 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 and contribute to the collection of data to monitor outcomes measures for the caseload Participate in the development of case management across the Trust. Provide clinical leadership and mentoring to those staff developing into a case management role Make, implement and communicate changes to clinical practice as necessary in relation to case management 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 Contributing to the development of policy and services to reflect the needs of the patient caseload. MANAGERIAL RESPONSIBILITIES Manage the complex clinical and social care interventions of individuals within an identified patient group on an ongoing basis. Undertake risk assessment in relation to individuals within the client group Monitor and respond to the development of changing clinical and social situations with the identified patient group without recourse to others where possible Ensure the safe management of care and service delivery Line manage a defined team of staff; including performing appraisal, personal development reviews and the application of staff management procedures Service Development Requirements Encourage patient and carer participation in case management through: The provision of information about disease prevention, progression and outcomes. Ensuring that services are accessible to increase patient confidence Empowering the patient to self manage whenever possible. Contribute to the development of role and service redesign in long term condition management. Analytical and Information Requirements The postholder will utilise data and data tools (including databases) to produce appropriate monitoring reports on both patient care and service outcomes and produce appropriate communication for patients Clinical Governance Requirements Participate in individual and group clinical supervision and action learning sets, and to take responsibility for developing own learning. Participate in research and audit relating to long term conditions management. Ensure systems are in place for ongoing review and assessment of care provision and delivery. Improve quality via Clinical Governance, Essence of Care and Clinical Supervision, by working closely with colleagues to address competency levels within the service. Report any incidents through application of trust policies. Participate in patient satisfaction reporting to improve patient care. Education and Training Requirements Promote formal and informal training to pre and post registration health and social care professionals in relation to integrated working and provide mentorship and teaching to others developing a case management function. Participate in the induction of new staff. Provide education, advice and support to health and social care staff, people with long term conditions and their carers in both community and acute settings. Maintain up to date knowledge and competence in line with professional and service requirements and demonstrate critical thinking, decision making and reflective skills to ensure own professional development. Communication/Relationship Requirements 37. Liaise with patients and carers, community and specialist nursing and other health professionals, GPs, acute colleagues, social care colleagues and the voluntary/charitable and non-NHS sector. Work with patients and carers to: Ensure that their values, beliefs and views are reflected in the case management plan Encourage active participation in case management Ensure that health advice and social care is provided in a professional, accessible and supportive way. Work with other professional and statutory groups involved in case management to: Ensure that there is consistent and high quality implementation of care Avoid duplication, delay or distress to patient Ensure that record keeping is consistent with Trust and Professional standards. Communicate at all levels of the organisation to a variety of health and social care professionals to provide best outcomes for patients.

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