YICT Nurse
Job Description
Job summary
We are seeking a motivated individual with a solution focused attitude to work as a Nurse as part of York Integrated Community Team /Frailty Hub. This key role is vital in providing a comprehensive care coordination to facilitate the appropriate delivery of health care services whilst providing professional, competent and efficient care that meets patients health and social needs.
Working directly with the Frailty Hub you will support this multidisciplinary team in the prevention of unnecessary hospital admission. You will also be case managing patients with frailty and long-term conditions to support patients to remain independent in their own homes, while continuing with healthcare assessments, rehabilitation, and recovery.
In this busy challenging role you will be able to work on your own initiative, be comfortable in making decisions within the scope of the role whilst demonstrating an understanding of community services and using the guidance and support of the multidisciplinary team.
Nimbuscare are committed to supporting the professional development of our employees and fostering growth opportunities to help build a long and rewarding career with us.
Please note this role includes evenings and occasional weekends on a rota basis. You will also require use of your own car and a driving license.
Main duties of the job
The role involves acting as a patient advocate and care coordinator, ensuring patients receive high-quality, patient-centered care tailored to their individual needs and preferences. Key responsibilities include:
- Coordinating care for a group of patients, ensuring communication of their needs to relevant healthcare providers.
- Delivering care and supporting staff in assessments and evidence-based care delivery.
- Providing advice and guidance to carers and healthcare assistants.
- Working across various healthcare settings, including surgeries, home visits, and community care.
- Offering on-call telephone support on a rota basis.
- Mentoring and training healthcare support staff.
- Facilitating patient education, self-management of disease, and behavior modification.
- Ensuring continuity of care, particularly during transitions like hospital admission and discharge.
- Managing complex patients in their homes or care facilities, collaborating with multidisciplinary teams.
- Focusing on high-risk patients and those with multiple conditions.
- Promoting clear communication within care teams and supporting medication management.
- Participating in team meetings, audits, and data collection for improving patient care.
- Ensuring compliance with CQC requirements and maintaining accurate documentation.
- Acting as a main contact for patients and their families.
- Managing caseloads autonomously, meeting targets, and contributing to business goals.
About us
Nimbuscare is one of the largest 'at scale' providers of primary care in the North of England, caring for more than 250,000 patients across our 11 Member GP Practices.
We work collaboratively across the York area delivering new, innovative, and sustainable health care services.
As leaders in local care, our goal is to work together across the health and care system to improve the health, wellbeing, and experience of our patients.
To learn more about Nimbuscare please visit our website at www.nimbuscare.co.uk
In line with the General Data Protection Regulations (GDPR), Nimbuscare will use and hold your personal data for the intended purpose.
We are committed to safeguarding the welfare of children/vulnerable adults and expect the same commitment from all staff and volunteers.
Nimbuscare is committed to improving the diversity of its workforce to better reflect the communities we serve. We welcome applications from everyone and work to promote an inclusive supportive culture that values and celebrates our differences.
As a Disability Confident Committed employer disabled applicants who meet the essential criteria for this job are guaranteed an interview.
Please note Nimbuscare does not hold a license to sponsor any visa applications and we are unable to provide any advice about visas.
Job responsibilities
MAIN DUTIES OF THE ROLE INCLUDE:
Assist patients through the healthcare system by acting as a patient advocate.
To act as Care Coordinator for a cohort of patients; 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 organisations 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, e.g. 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 YICT and wider 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.
met.
Person Specification
Qualifications
Essential
- Current NMC registration
- Safeguarding Children Level 2 Training
- Safeguarding Vulnerable Adults Training
- Certification of Enhanced Criminal Record Check with childrens and/or adults barred list check(s)
Experience
Essential
- Experience of working in a Nurse role
Physical skills
Essential
- Use of own car and driving licence
Knowledge and Skills
Essential
- Communication Skills- Able to calmly, professionally and efficiently identify patients / internal customer needs
- Able to professionally and efficiently deliver patients / internal customer needs with a warm reassuring demeanour
- Able to skilfully signpost / refer the patient to the most appropriate person or alternative solution to their needs
- IT Literate- Competent in the use of Microsoft Applications and a proven ability to learn how to navigate and interrogate systems, input data with an attention to detail and follow processes and procedures
Capabilities and Attributes
Essential
- Team Work- Work effectively and professionally within a ...
