Community Matron

Job overview

An exciting opportunity has arisen for an experienced nurse to join the Community Matron team within the Kings Lynn and Coastal PCN’s.

The Community Matron team provides an urgent response to patients in crisis. Where an unplanned admission can be avoided, collaboration with other Health and Social Care Services such as GPs and Community Services will be required.

The successful candidate will need to have excellent communication skills and the ability to organise and prioritise their caseload, according to the needs of both patients and the service.

Enquiries welcomed.

Pevious applicants need not apply.

Main duties of the job

To provide advanced intensive case management and clinical nursing care to patients with long term conditions who are high intensity users of both primary and secondary care.

Please see job description for more information.

Detailed job description and main responsibilities

Main Duties & Responsibilities

• To assess and provide specialist interventions for patients with long term conditions to achieve quality of life and independence where possible. 2. To work within the integrated team and case managers to prevent unnecessary admission to hospital and/or facilitate early discharge from hospital. 3. To support the prevention of unplanned hospital admissions, responding to patients who require urgent assessments and in collaboration with the patient and community teams, set up management plans to enable the patient to stay at home where possible. 4. To work with all health care professionals and statutory / non-statutory agencies to provide a seamless, integrated service to our service users. 5. To provide a 7-day, 365 days-a-year service. 6. To facilitate and develop a service providing complex case management. 7. To proactively case-find patients who are very high intensity users of primary and secondary healthcare and/or are at high risk of unplanned admission to hospital. 8. To educate and support the members of the multi-disciplinary teams to intensively case manage these patients. 9. To intensively case manage and be accountable for their own caseload of patients with highly complex and unstable health needs. 10.Develop systems and processes to support intensive case management within the multi-disciplinary team and with partners across the health system. 11.Work with and refer appropriately to other agencies to enable identified patients to be intensively managed in a proactive way with the aim of preventing hospital admission, supporting early discharge and reduce GP contact. 12.Be a champion for people with long-term conditions. 13.The post holder will practice as a non-medical prescriber in accordance with the Trust’s non-medical prescribing policy, protocols, national policies and within one’s scope of competency. 14.To assess patients for assistive technology where appropriate. 15.Independently manage the caseload by maintaining a consistent throughput of patients. This should be achieved by ensuring patients are discharged in a timely manner, promoting patient independence in managing their own health conditions, encouraging self-care and condition self-management, sign posting to other appropriate services and by utilising strategies of health promotion and health coaching. 16.To provide clinical support community teams at times of high / increased demand.   17. Communicate complex information to patients utilising motivational and persuasive skills  to support patients to self-manage or where there are barriers to understanding.   18. Demonstrate empathy and reassurance skills to convey sensitive / distressing  Information.

Please see attached Job Description / Person Specification for further information.