Community COPD Nurse/Physiotherapist

Oxleas NHS Foundation Trust; Greater London; On-site; GBP 40,000 - 52,000; Full time

Job summary

Oxleas NHS Foundation Trust is seeking a registered nurse or physiotherapist with respiratory experience to join the COPD team. The post focuses on complex case management, preventing hospital admissions, and coordinating care across primary and secondary settings.

You will work within an MDT, using advanced clinical skills to plan, implement and review COPD care, including self-management education and pulmonary rehabilitation. A flexible, community- and hospital-based role is envisaged.

Qualifications

• The COPD Community Matron / case manager provides expert care to COPD patients within the Greenwich GP network.
• Role requires advanced clinical assessment, diagnostic reasoning and case-management skills.
• Experience delivering COPD care in a primary/secondary care interface is preferred.
• Ability to work autonomously and within an MDT, using clinical governance to guide practice.

Responsibilities

• Proactively manage a caseload of COPD patients to prevent hospital admissions.
• Take autonomous clinical decisions and develop care plans with GPs where needed.
• Deliver advanced assessments and monitoring to detect early COPD exacerbations.
• Lead and mentor others within the MDT to ensure consistent COPD care.
• Coordinate with community matrons, district nurses and pulmonary rehab leads.
• Support self-management education and GRACE pulmonary rehabilitation initiatives.

Skills

Advanced clinical assessment

Case management

Autonomous working

Team collaboration

Education

NMC registered nurse

HCPC registered physiotherapist

Tools

iPad

Job description

**Important Sponsorship Information for this post: We are currently unable to offer a certificate of sponsorship for this post**

We have an exciting opportunity for a nurse or physiotherapist with previous experience managing respiratory patients, either in acute or community setting, to join the innovative COPD team.

The team comprises of a mixture of matrons, physiotherapists, a dietitian, a clinical psychologist, administrative support and healthcare/therapy assistants. Clinical leadership is provided by a Consultant Chest Physician from the Lewisham and Greenwich NHS Trust.

The COPD team delivers a wide range of services including:

• An SOS admission avoidance and early supported discharge services
• Pulmonary rehabilitation (PR)
• Self management education session enabling the patients to manage their disease in a much more proactive way
• Home oxygen assessment and review service

The successful candidate will be a registered nurse/physiotherapist with the relevant experience who will support the team to manage their own COPD patient caseload. They must be comfortable and confident to work alone and within the wider MDT.

The SOS service delivers care Mon- Sun, 9-5pm and is managed by 2 clinicians per day, except the weekends where 1 person is rostered on.

Computer literacy and the ability to use an iPad for remote working is essential.

Oxleas operates a probationary period, further information is available on request.

Main duties of the job

The post holder will proactively manage a caseload of patients requiring complex case management in order to prevent hospital admissions and improve patient health outcomes.

Working autonomously, the post holder will have continuing responsibility for proactively monitoring and managing, patients on the caseload. The post holder will be expected to possess skills in advanced clinical assessment, diagnostic reasoning and using these skills will assist in the recognition of early symptoms of disease exacerbation.

The post holder will be expected to be a competent leader and case manager and critical thinker navigating the patient through the COPD care pathway which spans across the primary, secondary care interface. Pivotal to the care pathway is the prevention of unnecessary admissions and facilitation of early supported discharge to reduce lengths of stay.

The post holder will be expected to work according to their shift allocation as organised on health roster every 3 months.

About us

Oxleas - About Us

Oxleas offers a wide range of NHS healthcare services to people in community and secure environment settings. Our services include community health care such as district nursing and speech and language therapy, care for people with learning disabilities and mental health care such as psychiatry, nursing and therapies. Our multidisciplinary teams look after people of all ages and we work in close partnership with other parts of the NHS, local councils and the voluntary sector and through our new provider collaboratives. Our 4,300 members of staff work in many different settings including hospitals, clinics, prisons, secure hospitals, children's centres, schools and people's homes.

We have over 125 sites in a variety of locations in the South of England. In London we operate within the Boroughs of Bexley, Bromley Greenwich and into Kent. We manage hospital sites including Queen Mary's Hospital, Sidcup and Memorial Hospital, Woolwich, as well as the Bracton Centre, our medium secure unit for people with mental health needs. We are the largest NHS provider of prison health services providing healthcare to prisons within Devon, Dorset, Bristol, Wiltshire and Gloucestershire, Kent and South London. We are proud of the care we provide and our people.

Our purpose is to improve lives by providing the best possible care to our patients and their families. This is strengthened by our new values:

• We're Kind
• We Listen
• We Care

Job responsibilities

The COPD Community Matron / case manager will be expected to:

• To be responsible and accountable for providing expert care to COPD patients who are registered with a Greenwich GP
• Utilisation of advanced clinical skills and expert knowledge to plan, implement, monitor and review individualised patient-directed programmes of care to patients with COPD including health promotion interventions.
• To undertake goal centred interventions that are evidence-based, evaluating the effectiveness of these at regular intervals with a view to improving care continuously.
• Develop risk management plans that will enable individuals to remain safely within their homes
• Use expert knowledge and skills as a non medical prescriber to manage patient medication within own areas of competency, developing clinical management plans in partnership with GP colleagues where necessary.
• Anticipate individual care needs and develop appropriate care plans, involving carers and relatives
• To provide individuals and their carers with the necessary education that will enable them to plan for unavoidable disease progression and self manage as far as possible.
• To work collaboratively with members of the multi professional team to ensure that the patients needs are met, making appropriate referrals are made where necessary.
• Develop practices which promote patient choice and well-being
• To be responsible for ordering stock and other resources when asked
• Ensure that the needs of individuals who are vulnerable are highlighted and addressed in a timely manner
• To be a competent clinical leader demonstrating a willingness to work as an integral part of a multi professional team
• Be a highly skilled communicator, written and verbal, with a capability for communicating within a variety of professional groups, challenging attitudes where necessary
• To manage a caseload of patients with COPD (Specialist community matron/case manager)
• To practice at an advanced level demonstrating an in-depth knowledge of all aspects of the management of COPD that is evidence-based
• To undertake advanced physical and social assessments and examinations, and initiate appropriate diagnostic activity and treatment
• To work with other community matrons/case managers to ensure a consistency of approach to patient care and to support clinical supervision arrangements within the Trust
• To work collaboratively with other specialist and multidisciplinary teams, such as GPs, District Nurses, Consultants
• To support the and COPD self management programmes such as GRACE and pulmonary rehabilitation
• To contribute towards reducing frequent admissions and bed days of patients with COPD
• To help improve the diagnostic rate of COPD in primary care supporting the delivery of an ARTP accredited quality assured spirometry clinic.
• To work alongside the clinical lead in the new/confirmed diagnosis of COPD in producing treatment plans including self-management and education at consultant lead MDT sessions
• To participate in the delivery of education sessions on the Greenwich Respiratory Advice and self-Care Education (GRACE) programme in a community
• To be confident in the delivery of educational topics including: pathophysiology of COPD, COPD medications, managing exacerbations, breathlessness, productive cough, anxiety and low mood and the importance of exercise and a balanced diet
• To participate in the delivery of pulmonary rehabilitation with the support of the pulmonary rehabilitation lead
• To participate in disease specific audit and data collection
• To act in accordance with the clinical governance framework within the Trust
• To share knowledge and skills with patients and families as a key therapeutic intervention and to enable self care and autonomy
• To identify the educational requirements of primary and social care colleagues in relation to the management of COPD and lead on meeting these needs
• To participate in clinical supervision, appraisal and personal development programme
• Ensure own professional development and clinical skills through attending courses, workshops and conferences and applying the knowledge gained in clinical practice
• To interface with primary and secondary care teams to enable the implementation of managed care pathways in line with local and national guidance
• To advise on and develop new initiatives and ways of working informed by local and national policy
• To be involved in the development of guidelines, policies and protocols within the Trust
• To promote effective collaborative working relationships with health and social care colleagues and those within support networks and the voluntary sector
• To act as a change agent and innovator, planning, instigating and evaluating changes
• To proactively demonstrate the positive impact of case management on the reduction of avoidable admissions and lengths of hospital stay
• Contribute to the service development within the Trust in line with national strategies particularly the COPD
• To maintain accurate and legible and timely records
• To act as leader, mentor and preceptor to staff within the Trust

Person Specification

degree/diploma

• post grad modules in respiratory

Experience

• 5 years experience
• community experience
• delivery of self management
• Demonstrates leadership skills within an MDT

car driver and user

• access to car

Clinical Skills

• Experience of managing complex respiratory patients in secondary or community care

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.