Bank Community Matron

Job overview

• To co-ordinate care provision through a case management approach with the aim to prevent unnecessary hospital admission and facilitate timely discharge.  The caseload supports patients with multiple co-morbidities including frailty, COPD, Parkinson’s, diabetes, dementia, and CHD.
• To provide the highest standard of clinical care by using advanced skills and expert knowledge to holistically assess needs and instigate and provide clinical treatments based on evidence-based practice.
• To participate in the delivery of educational programmes to patients, carers and health and social care workers that promotes self-care principles.
• To develop and promote robust multidisciplinary team (MDT) working across the wider Health and Social care sectors, including care homes, to ensure integrated service and support networks for patients.
• To monitor the quality-of-care provision and to identify and promote areas for service development.  To be the named Community Matron for a Primary Care Network (PCN), providing support and care coordination for the wider health team within the network.
• To provide clinical leadership and support to end of life pathways, including the Universal Care Planning (UCP) framework.

Main duties of the job

• To work in partnership with community health, social care and third sector organisations including care homes.  Proactively case finding with GPs, district nursing colleagues and providing links across community nursing.
• Working closely with care home aligned GPs and care home staff to support and offer your expert advice.
• To work in partnership with acute Trusts through attending at high intensity user forums, linking with frailty and discharge teams and London Ambulance Service.
• To support and coordinate the Westminster Integrated Domiciliary Service.
• To work as a member of a PCN in line with the Westminster Integrated Care Partnership and the NWL Integrated Care Systems.
• Liaise closely with NWL Leads and CLCH Academy on any new initiatives and training to support the service.

Detailed job description and main responsibilities

• To use advanced skills and expert knowledge to carry out a thorough assessment and history taking, including a systematic physical examination, in order to develop a comprehensive care plan.
• To initiate, and provide, advanced clinical / therapeutic care treatments, in partnership with other providers, based on best possible evidence that will improve health outcomes.
• To use advanced clinical skills and expert knowledge to proactively identify subtle changes in a patient’s condition as early as possible and to manage these in a manner that optimises well-being.
• To take overall responsibility for coordinating the care, treatment, and complex health funded packages of care for case managed patients in a variety of settings. This includes planning, developing, implementing, monitoring, and reviewing specialised programmes of health interventions for case managed patients.
• To review and complete UCPs for patients.
• To work within the principles of the Single Assessment Process.
• To maintain responsibility if a patient is admitted to an in-patient facility. This includes actively accessing the acute sector to provide base line health data to appropriately the receiving team and initiating early discharge for case managed patients.
• To appropriately refer patients for a range of physical and functional tests and assessments, in order to inform decision making and care pathway development.