Dementia Matron

Job overview

This role is offered on a fixed term/secondment basis for 12 months. The hours are part-time, 15 hours per week.

Internal applicants who wish to be considered for a secondment opportunity should discuss with their line manager the suitability of a possible secondment.

The Complex Care at Home Community Dementia Matron assumes the role of an autonomous Practitioner, responsible for overseeing the care of their assigned patients. This entails triaging, planning, managing, and coordinating intricate care and treatment requirements within the confines of patients’ homes. As a member of the Complex Care at Home Multidisciplinary Team, they proactively take a lead clinical role, responsible for planning, managing, and coordinating the care of individuals with highly complex needs and long-term conditions within a defined caseload of people with dementia. The Community Dementia Matron collaborates closely with primary and secondary care services, including Physical and Mental Health, as well as statutory and non-statutory agencies. This collaborative approach enables the development of personalised care plans, consistently advocating for the ‘What matters to you?’ principle.

Main duties of the job

• Take a lead role within a multidisciplinary team, proactively managing a caseload of complex patients living with dementia, long-term conditions, and/or frailty, and at risk of deterioration. Patients will be identified through an agreed case-finding approach and from referrals received from primary and acute care teams.

Utilise a case management approach to support patients, carers and families to live well with their Dementia to prevent avoidable health deterioration & hospital admission, or unnecessary length of stay.

• Gather and interpret complex clinical data for the purposes of a comprehensive health and social care needs assessment involving a multi-agency/partnership case management approach. They will also be responsible for identifying and facilitating assessments of health and social care needs, gathering data, and interpreting complex clinical information to plan care appropriately. Ensure an effective and evidence-based service is delivered using advanced assessment and planning to implement case management programs for patients. The qualification, training & experience requirements for the role are underlined in the Job Description/Person Specification.

Detailed job description and main responsibilities

• Provide specialist knowledge and support to other team members. They will also advise on non-complex mental health issues such as depression and anxiety, understanding the opportunities and processes for referring or signposting individuals with more complex mental health problems.

Work collaboratively with the patient, family and carers applying a health coaching/motivational interviewing skilled approach to problem solving and enabling appropriate self- management.

Undertake a holistic assessment, care planning of identified patients, ensuring health gains and maximising independence.

Ensure that all patients identified with a cognitive impairment have equity to GHC specialist memory assessment service by ensuring they adhere to the Complex Care at Home Dementia Pathway (2019)

Work autonomously as a Mental Health Specialist linking in with Primary, Secondary and Territory service to promote equitable treatment and transition to appropriate care pathways.

Act as an autonomous practitioner within own localities and will provide supervision and management support for other members of the team

Responsible for developing and auditing the Dementia Matron Role service within Complex Care at Home to ensure that the Dementia Pathway is being adhere to across the three localities.

This role is not eligible for sponsorship as per the Government’s UK VISA and Immigration Rules and Regulations. For more information please visit https://www.gov.uk/browse/visas-immigration/work-visas