Specialist Neighbourhood Nurse

NHS Jobs; Long Sutton; On-site; GBP 36,000 - 48,000; Full time

Job summary

East of England Community Health & Care NHS Trust is seeking a Neighbourhood Nurse to support patients in the community, liaising with GPs, care providers and multidisciplinary teams to implement care plans and promote self-management.

You will visit homes and care homes, develop and review care plans, and coordinate with carers to reduce unnecessary hospital admissions while ensuring personalised, holistic care.

Responsibilities

• Act as a point of contact between GP, Neighbourhood Team, people and carers.
• Develop knowledge of local services to enable sign-posting.
• Liaise with GPs and practice teams to identify elderly or frail patients.
• Liaise with primary, secondary and specialist care services as required.
• Work with Neighbourhood Team to identify those at risk of loss of independence or admission to hospital.
• Signpost these cohorts to identified services to maintain independence and health.
• Visit people at home or in care settings to assess needs with carers as appropriate.
• Implement personal care plans and preventative actions to use services appropriately.
• Communicate the care plan to the GP and Neighbourhood Team and upload records.
• Ensure right level of help at the right time, liaise to provide joined-up service.
• Encourage self-management to reduce hospital admissions.
• Liaise with other agencies for timely engagement.
• Support access to community care and carers assessments.
• Advise on personal healthcare budgets when allocated.
• Identify unpaid carers and direct them to services.
• Identify urgent action and alert Neighbourhood Team with safety concerns.
• Follow up on communications from out-of-hospital and inpatient services.
• Undertake visits or calls to manage SNNs caseload after unplanned admissions.
• Participate in Practice MDT meetings to discuss Practice patients.
• Attend Neighbourhood Team MDT meetings at the Practice.
• Undertake visits or arrange appointments at the Practice for SNNs caseload as directed by Duty Doctor.
• Maintain accurate records using GP systems (SystemOne, EMIS, VMDT).
• Run regular patient searches using SystemOne/EMIS to keep KPI progress.
• Work with South Lincolnshire ICB and other agencies to develop this role.
• Support Practice Manager in providing KPI reports.

Job description

The development of Integrated Neighbourhood working is supporting Providers to work in a joined-up way. and Primary Care plays a key role in the success of Integrated Neighbourhood working, supporting patients to self-manage their condition or be assisted to manage their health needs closer to home, in their local communities. This approach enables more people with health and social care complexities to achieve a greater balance in all round health.To work dedicated hours to focus on proactively case managing people and being the preferred point of contact for the patient and Neighbourhood Team in order to achieve the following objectives: To be a pro-active member of the Neighbourhood Team To pro-actively engage with people deemed to be at a high risk of hospital admission To pro-actively engage with the in-reach teams to reduce length of stay in hospitals To pro-actively engage with people living in care homes To pro-actively engage with housebound people To be the key contact for people at the practice

3. Role summary

To liaise with the registered GP and other practice based staff in addition to all other providers and services utilising, where appropriate, a multi-disciplinary approach. To implement and review individual care plans, a self-management plans and to agree trigger thresholds to contact Case Managers & GPs. Plan visits to housebound people, undertake every 3-6 months, and arrange care plans where necessary Provide enhanced support to Nursing and Residential home with a focus on strengthening relationships and improving access through information sharing, education and advice. Planned visits to Nursing and Residential homes to be undertaken every 3-6 months, providing training as required. To ensure all people in Nursing and Residential homes have care plans including dementia where needed and to provide a holistic review of all people in these homes with updates of their care plans. To contact people where necessary to advise them of the role of Specialist Neighbourhood Nurse Visit people at home following the identification of urgent clinical need including those escalated by EMAS or a member of the Neighbourhood Team, undertake a personalised comprehensive assessment, in order to diagnose, treat and prescribe within the limitations of your registration and competence Visit people at home following an unplanned hospital admission and those with a history of repeat admissions, within 2 weeks. Contact those that have suffered a bereavement. Arrange dedicated appointments in practice, for those who wish to visit, with flexibility to expand up to 30 minutes, or as needed. Ensure all people with dementia have a care plan.

4. Key Responsibilities

• Act as a point of contact between GP, Neighbourhood Team, people and their carers.
• Develop and maintain a detailed knowledge of local services to enable supported sign-posting of people with identified need, sharing information with the Neighbourhood Team.
• Liaise with GPs and practice teams to identify people who are elderly, frail or who have long term health needs and support.
• Liaise with primary, secondary and specialist care services as required.
• Work with the Neighbourhood Team to help identify people at risk of loss of independence or admission to hospital as a result of inadequate social support.
• Provide these cohorts of people signposting to identified services in order to maintain their independence and improve their health and well-being.
• Visit people in community, home or care home settings to assess and discuss their care needs involving carers as appropriate.
• Implement personal care plans for individual people, ensuring preventative actions are detailed to support the appropriate use of services.
• Communicate the care plan to the GP and any other members of the Neighbourhood Team involved in the persons care and upload to the relevant records.
• Ensure that identified people receive the right level of help at the right time and help them to experience a joined up service by liaising with relevant members of the Neighbourhood Team.
• Work with patient, carers and the Neighbourhood Team to encourage the patient to adopt effective self-management and self-help seeking approaches to reduce unnecessary hospital admissions.
• Liaise with other agencies to ensure timely and appropriate engagement as required.
• Support people to access community care assessments as well as carers assessments.
• Where a personal healthcare budget is allocated provide advice as required regarding the key choices the patient will need to make.
• Identify unpaid carers and direct them to access services as appropriate to provide them with support.
• Identify when urgent action or a step up in care is required and promptly alert the relevant member of the Neighbourhood Team, highlighting any safety concerns.
• Follow up on communications from out of hospital and in-patient services regarding changes in condition of people to support the practice to respond proactively to potentially unmet needs.
• Undertake visits or telephone contact to manage people on the SNNs case load following any unplanned hospital admissions where appropriate.
• Participate in Practice multi-disciplinary meetings to discuss Practice people actively being managed by the Neighbourhood Team and any other people from the SNNs case load needing discussion.
• To attend Neighbourhood Team MDT meetings at the Practice plus any other meetings where there is a need to discuss Practice patients.
• Undertake visits or arrange appointments at the Practice for people on the SNNs case load or otherwise as directed by the Duty Doctor following identification of urgent and non-urgent clinical need to assess, diagnose, treat, prescribe and refer appropriately according to the patients health needs and acting within the SNNs clinical skill set.
• Maintain accurate and up to date records of patient contacts using GP record systems and other IM&T systems relevant to the role i.e. entering notes onto Systemone , EMIS using agreed read codes and VMDT
• To run regular patient searches using Systemone , EMIS in order to have an up to date record of progress of achievement of Key Performance Indicators.
• Work with South Lincolnshire ICB, Neighbourhood Teams and other agencies to support and further develop this role.
• Support the Practice Manager in providing KPI reports for submission as requested.

5. Key Working Relationships

Practice teams Neighbourhood Team Community health services Specialist teams heart failure, diabetes etc. Specialist nursing services e.g. St Barnabas Hospital teams including ward, A&E, discharge and AIR teams Social Prescribers Health & Wellbeing Coaches Safeguarding agencies Pharmacists South Lincolnshire ICB Adult Social Care Voluntary Services Independent Care Homes Local Authority teams Independent living teams

6. General duties

Health and Safety - It is the responsibility of the individual to work in compliance with all current Health and Safety legislation and the Practice Health and Safety Policy. To attend any training requirements, both statutory and mandatory, in line with the legal responsibility to comply with the Health and Safety at Work Act 1974. The roles contains the following responsibilities: To maintain registration with the NMC. To adhere to the NMC Code. To support training and development. To maintain personal professional competency and appropriate development. To carry out the duties and responsibilities of the post in accordance with the Practice Policies including duty of candour and whistleblowing. Required to comply with all relevant national and local statutory and mandatory requirements including Health and Safety, Infection Control, Safeguarding, Information Governance, Research Governance and Equality and Human Rights. The post holder will work in an environment where individual differences and the contributions of all staff are recognised and valued. All employees, people, carers and the public are entitled to be treated with dignity and respect and no form of discrimination, intimidation, bullying or harassment will be tolerated. We adhere to and believe in the NHS People promise We are open and inclusive. We understand, encourage and celebrate diversity, making the NHS a place where we all feel we belong. This Job Description is not an exhaustive list and will be reviewed in the light of changed needs and organisation development. Any changes will be discussed with the post holder who will be required to carry out other duties appropriate to the grade and scope of the post. The post will involve regular travel locally and regionally on occasion and the post holder may be required to undertake occasional evening or weekend work.

East of England Community Health & Care NHS Trust

East of England Community Health & Care NHS Trust