YICT Nurse

Assist patients through the healthcare system by acting as a patient advocate. To act as Care Coordinator for a cohort of patients; in order to meet patients' needs and preferences in the delivery of high-quality, high-value health care. Ensuring throughout that the patient's needs and preferences are known and communicated at the right time to the right people, and that this information is used to guide the delivery of safe, appropriate, and effective care. Deliver and delegate Patient-Centred care based on individual need. Provide support and advice to carers and HCA in assessment of patients and enable them to deliver evidence-based care. Required to work from any surgery site or any other health care settings (e.g. home visits, in the community, as deemed necessary to the smooth running of the Practices Required to offer on call telephone support to the wider team Out of normal working hours on a rota basis. Act as Mentor to Health Care Support team members helping to identity and deliver appropriate training. Facilitate health and disease patient education. Support patient self-management of disease and behaviour modification interventions Coordinate continuity of patient care with external healthcare organizations and facilities, including hospital admission and discharge and referrals from the primary care provider to a specialty care provider. Coordinate continuity of patient care with patients and families following hospital admission, discharge, and A&E visits. To manage complex patients effectively and efficiently in their own home/care home contributing to the work of the wider multidisciplinary team. To work within the Frailty Hub, assisting in the coordination of patient care to deliver appropriate and timely actions to prevent hospital admission. To liaise with all other community teams, eg primary care, secondary care, social care, and voluntary sector Manage high risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting, including a registry. Conduct comprehensive assessments for patients and/or assist all support staff in daily patient interactions as needed. Promote clear communication amongst the care team and treating clinicians by ensuring awareness regarding patient care plans. Facilitate patient medication management based upon standing orders and protocols. Participate in York integrated care team multi-disciplinary team meetings. Participate on a team for data collection, health outcomes reporting, clinical audits, and evaluation related to the Patient-Centred YICT initiative. Evaluate clinical care, utilisation of resources, and development of new clinical tools, forms, and procedures. To ensure any CQC requirements and/or documentation for which the post holder is responsible for is completed timely and accurately. To also ensure any procedures and processes applicable to the role are followed timely and accurately. To ensure you devote the whole of your time at work, attention and abilities to your role, our business, and its goals. To facilitate the use of advance care plans within patients own home/care home setting. Act as named point of contact for patients and their carers. Such other duties as may reasonably be delegated from time to time. Manage caseload autonomously to ensure targets are met.

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