Senior Nurse Practitioner

Job Purpose To participate in providing a Nurse-led standardised level of support and care for Nursing, Residential and Learning Disability Care Homes in Kingston, working in partnership with care home providers. Focusing on promoting proactive care delivery and development of evidenced based clinical policies to improve standards and raise levels of knowledge and skills through education and support. Being part of the Urgent Community Response Service, to provide an urgent care service to care home enabling residents to be assessed, diagnosed and receive appropriate treatment reducing unnecessary A/E attendance. To participate in working with care home staff to manage residents with complex or long-term conditions, clinically assessing and prescribing to prevent admission to hospital and advising on nursing intervention to avoid deterioration. To support the team to case manage patients with exacerbation of long-term condition/complex conditions enabling care homes to prevent crisis situations arising, thereby avoiding inappropriate hospital admissions To provide teaching packages to care home staff to reduce unnecessary admissions and improve clinical competence of care home staff To work in partnership with the care home to improve the quality of care by providing enhanced clinical assessment, intervention and diagnostics and prescribing 3. Dimensions Monitor hospital admission, A&E attendance & ambulance call rates for individual care homes in the Kingston borough, targeting support to care staff in care homes where emergency admission rates are high. Provide advice support and clinical input to residents Identify complex patients requiring case management Provide guidance on safe practice for individual residents to prevent unnecessary emergency hospital admissions, particularly in relation to end of life care. Provide training and support to care homes to encourage them to provide high-quality care to residents with complex needs and those approaching the end of life. Support care homes in identifying training needs and recommend/sign post to appropriate training for staff. Provide training & support on a range of subjects, provide developmental training programmes for care homes to adopt which would embed nationally recognised care practice (i.e. NICE Guidance) for long term conditions. Work in collaboration with other Health Care Professionals services for patients identified at risk of admission e.g. SALT, Dietician, Diabetes Nurse Specialist, Tissue Viability Nurse Specialist, and Continence Nurse Specialist. Extended Scope Practitioner Lead Respiratory Physiotherapist Support care homes, linked G.Ps and Adult Services to work collaboratively to achieve effective communication and provision of proactive medical/nursing/therapeutic care to prevent unnecessary hospital admissions. Collect data as required supporting audit focusing on health outcomes and reduction of acute hospital emergency bed days. 4. Key Result Areas Clinical Use clinical reasoning and physical assessment to assess, diagnose and treat the physical and psycho-social needs of residents with complex needs or those at risk of hospital admission. Work with the care home to instigate therapeutic treatments based on best available evidence to improve health outcomes. Use skills and clinical knowledge to support the care home staff in identifying and monitoring subtle changes in the condition of residents/patients and in taking appropriate action to prevent/manage. Work with the care home staff to recognise and interpret cues, signs and symptoms, instigate investigations and interpret results to formulate a diagnosis. Use skills and knowledge to make both a comprehensive and focussed assessment. Order investigations as necessary. Support the care homes in developing personal care plans and crisis management plans with residents carers, relatives and health professionals based on full assessment of medical, nursing and social care needs. Provide expert clinical care support and health promotion interventions. Support nursing homes with Advanced Care Planning, DNAR, Assessment of symptoms prescribing of EoL drugs and verification of death Provide support with the implementation of evidenced based clinical policies to underpin effective and consistent care management Use knowledge and skills to prescribe medication as allowed within competency and provide advice to patients and their carers on medicines management. Work in partnership with GPs. Co-ordinating the seamless transfer of residents to appropriate services. Negotiate and agree with the patient, carers and other care professionals, individual roles and responsibilities with actions to be taken and outcomes to be achieved, referring on to other services or professionals as appropriate. Challenge professional and organisational boundaries which prevent delivery of integrated health and social care to prevent health deterioration or hospital admission. Identify areas for skill/knowledge development and apply these to practice to provide continuity and high-quality patient-centred health care. Mobilising additional support as needed, e.g. palliative care, colleagues in the Joint Service Directorate, Adults Services and Carers Support Service. Establish a network that can be used to streamline care pathways, working in partnership with other agencies. Ensure effective co-ordination of care for individual residents within the care home setting Ensure care homes provide baseline health data if the resident is admitted to hospital to support integrated, consistent care and facilitate discharge. Work with the multi-disciplinary team to plan and implement high quality care. Influence, develop and pioneer changes in practice within care homes. Identifying patients who have complex care needs to formulate appropriate management Develop integrated care pathways between care homes, and A&E staff teams. Champion Older People's issues in a variety of settings and Professional groups. Initiate actions/recommendations relating to care homes to help reduce hospital admissions and delayed transfers Educator Assist care home staff and other Professionals to enable competence and development of skills/roles in accordance with DH principles. Work with and teach residents and carers to identify subtle changes in condition that may precipitate acute exacerbation of underlying condition or illness and assist in advising on the action to be taken ensuring care plans reflect this. Work with the multi-disciplinary team to develop integrated skills training for residents, informal carers and care home staff to promote independence; plan for unavoidable progression in conditions and educate in the areas identified as causes for A/E admissions e.g. UTI, dehydration, falls, chest infections/ aspirational pneumonia, palliative care and enhance dementia care practice. Communicator Use a high level of interpersonal, IT and communication skills to communicate effectively with residents and care home staff, including communication of sensitive and complex information about individual condition. Prepare residents and their families for changes in condition and support choice about end of life care in partnership with palliative care team Effectively communicate at all levels of the organisation with a variety of health professionals, users and carers to provide the best health and social care outcomes for older people. Provide the interface between hospital and Primary, Community & Social Care and Care Home settings. Maintain a high level of performance and be goal and outcome focussed when faced with opposition or when working under conditions of pressure. Keep accurate timely documentation. Provide high quality written reports and any other written documentation as necessary. Listen and empathise with the needs and wishes of users and their carers. Line Management To ensure the smooth and efficient running of the service in partnership with the Advanced Nurse Practitioner/Urgent care & support service lead, the overall strategic direction and development of the Service. To line manage team members this includes appropriate delegation and organisation of workload within the team whilst, absence and performance management. To support the Advanced Nurse Practitioner/Urgent care & support service lead in promoting a style of leadership that develops and empowers staff, recognising achievements and providing support and assistance. To support the Advanced Nurse Practitioner/Urgent care & support service lead to implement change and improvement in services and systems including ascertaining and developing the medical competencies of employees. To manage and resolve informal and formal complaints and ensure that staff understand and comply with the NHS complaints policy. To ensure staff practices within the framework provided by the YH Policies, Procedures and Guidelines and those laid down by nursings regulatory body. To assess referrals to ensure they meet the clinical criteria of the Urgent care & support service. To participate in the development and integration of care pathways, policies and procedures that will influence service delivery and practice.

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