Specialist Nurse for Care Homes

Job overview

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

Our ‘Home First’ vision is for Greenwich residents to receive the highest quality of care in the safest environment and wherever possible this will be their home.

An exciting opportunity in the Adult Community Physical Health Services directorate has arisen for a Specialist Nurse for Care Homes in Greenwich. This is a positive time to join us as we embark on a range of transformation projects within our services. Our ‘Home First’ and Virtual Ward programmes are well established and have supported keeping patients at home instead of being admitted to hospital. The successful applicant will be a crucial part of our model within Care Homes to support care in the community and promote health and wellbeing for residents of care homes in Greenwich.

Main duties of the job

The Complex Case Management in Care homes service utilises an MDT approach under the Enhanced Health in Care homes framework (EHCH). The postholder will act as a Senior Nurse and work closely with Primary care, community services, Care Home Managers and Social Care teams to support effective interventions for Care Home residents. The aim of the role is to reduce hospital admissions and maintain high standards of care in the community.

The post holder will work across a range of organisations and services and provide clear coordination of the EHCH model for Greenwich. To ensure the coordination of agreed interventions are planned, managed and delivered effectively with support of the MDT. This will include direct working relationships with Care Home Staff, Geriatricians, LAS, GP’s, other Primary Care professionals and Adult Social Care with the inclusion of other service providers when appropriate.

• Have a good understanding of working with complex health issues and particularly older adults living with frailty, residing in Care Homes
• Able to build good relationships with key stakeholders and the MDT and communicate effectively.
• Have experience of working with an MDT and be able to lead staff of different disciplines, working collaboratively with medical colleagues.
• Work closely with key stakeholders in South East London.
• Work as part of the Greenwich Home First and Virtual Ward programmes to develop care closer to home and support early hospital discharge.

Detailed job description and main responsibilities

• To support the on-going delivery of a robust and resilient Enhanced Health in Care Homes Model in Greenwich by conducting modified Comprehensive Geriatric Assessments and participating in weekly virtual Multi-Disciplinary Team (MDT) reviews of patients on the caseload.
• To support coordination of the MDTs with partners for an agreed cohort of individuals who are Care Home residents with multiple health needs or are high intensity users of A& E with multiple presentations.
• Working with the MDT including GP’s, Care Home Staff and acute hospital including consultants and other key system partners in identification of frequent attenders and production of Advance Management Plans.
• Maintain regular contact for GP’s, LAS and other service providers to flag up high impact users to prevent hospital admissions.
• Organising and chairing the virtual MDT meetings, in the absence of the service lead, ensuring attendance and engagement of key players.
• Profiling and highlighting agreed MDT outcomes, ensuring action is taken for the cohort of individuals identified including robust plans of care, anticipatory care planning is in place.
• To ensure collaborative working is undertaken across Greenwich with regards to frequent attenders/ high impact users/multiple emergency spells.
• Complete a data base of this cohort of patients. Utilising this to implement a more robust model within Greenwich for the overall identification and management for this cohort of patients.
• Actively contribute to capacity planning and review processes and link to the Frailty PCN Model.
• Take a lead role in the use of Universal care plan completion and maintenance for care home patients and support the MDT to ensure this is utilised effectively.