Community Heart Failure Specialist Nurse

Job overview

The post holder will be community based and will provide expert clinical knowledge and skills in the management of patients with a confirmed diagnosis of Heart Failure.  They will hold a specific caseload of patients focusing on patient management to avoid unplanned admissions to hospital and educating and optimising treatment for newly diagnosed heart failure patients.

They will be expected to liaise with the MDT to provide assessment and follow-up of patients with a confirmed diagnosis of heart failure - ensuring optimal therapy and promotion of education towards self-management.  They will be expected to liaise with GPs, secondary care, other community services and social services to develop a multi-disciplinary approach towards improving the care and management of patients with a diagnosis of Heart Failure.

They will work on nursing issues relating to Heart Failure in line with NSF standards, local and national guidelines, influencing the Strategic planning for Heart Failure service delivery in line with NSF standards.

Main duties of the job

• Manage and facilitate the care of patients with Heart Failure in the community through outpatient clinics and home visits.
• Providing specialist assessment for individuals with heart failure and co-ordinate individual care plans to maximise health outcomes.
• Use advanced clinical skills and evidence-based knowledge to identify investigation and/or treatment needs of individuals.
• Provide medicines management support and advice in accordance with national and local guidelines.
• Provide appropriate advice and support to patients and their carers including the provision of education and the promotion of self-management skills.
• To liaise with local cardiac rehabilitation teams and End of Life teams as appropriate.
• Act as a specialist resource for patients, their carers and other health professionals to improve the management of patients with heart failure.
• Liaise closely with primary and secondary care services to provide an integrated care plan in which the patient and carers participate.
• Ensure mechanisms in place for escalation of care at times of clinical deterioration
• To triage referrals from GPs, consultants, inpatient heart failure team and other professionals and service in agreement with individual patient.
• Provide empowerment and support, acting as an advocate to enable individuals and their carers to actively engage in agreed treatment programmes.

Detailed job description and main responsibilities

Please see attached job description and person specification for more information.