Are you a Registered Nurse with an interest in caring for people living with long term conditions and increasing frailty, to support them to remain living independently at home or in a residential care setting, ensuring planned, optimised, and co-ordinated health care for them and their families?
Poole Central Primary Care Network provides services on behalf of five GP Practices to the population of central Poole town, Hamworthy, Upton, and Lytchett. We are looking to recruit a Registered Nurse to our Enhanced Care Team, ideally with previous experience in a community or primary care setting who would like to join our multi-professional Enhanced Care Team, providing both on-the-day urgent support and proactive planned care and long-term conditions management.
As an experienced RGN, the role will be to coordinate the clinical case management for frail and complex health patients, who are at risk of further deterioration in health, an avoidable hospital admission, or unnecessary length of hospital stay.
This role is offered on a part-time/full-time basis and is open to a flexible working pattern.
Main Duties of the Job
To work as a member of the Poole Central Primary Care Network Enhanced Care Team to coordinate clinical case management for frail and complex patients and those with long term conditions who are at risk of further deterioration in health or an avoidable hospital admission or unnecessary length of hospital stay. To be responsible for a caseload of patients who have either been identified using an agreed case finding tool (Electronic Frailty Index or Rockwood) or whom have been identified by another healthcare professional as frail or as having a long-term condition. As part of a team approach, to be responsible for identifying an individual’s principal needs through a holistic, comprehensive assessment, develop care plans, and work closely with other members of the MDT and primary care/community care team to support patients in the community. To support preventative care, screening, and patient education to enable the patient to manage frailty and long-term conditions. To be adaptable and able to work across all aspects of the service, including where needed, supporting the Care Home and Acute home visiting services. About Us
Poole Central PCN is the second largest PCN in Dorset and one of the first to develop an operational Hub with a central co-ordination team and clinical teams co-located in a dedicated building. The PCN services comprise a multi-professional Enhanced Care Team, responding to the needs of the population who are housebound or living in long-term residential care. The ECT comprises ANPs, RNs, HCAs, Paramedics, Specialist Diabetes and Respiratory Nurses, and Clinical Pharmacists, working together to optimise clinical outcomes and support people to remain living independently whenever possible and working closely with Practice Teams to ensure effective co-ordinated care. We work collaboratively with partners in health and social care and are currently developing a number of pathways that involve models of integrated working, and information systems and digital technology have a key part to play in achieving greater efficiency in how we work. The post-holder will be employed through The Adam Practice (Lead Practice) on behalf of the PCN and details of Terms and Conditions of employment are available on request. Job Responsibilities
To undertake a holistic full assessment of the physical and psycho-social care needs of complex and frail patients and those with long term conditions, involving carers and relatives. To establish an individual’s functional capabilities with regards to frailty, as well as ability to manage other long-term health conditions. To provide cognitive assessment and identification of mental health needs, referring as appropriate. To identify an individual’s principal needs and support them in the development of plans to address related issues, supporting self-management where feasible. To develop a person-centred, evidence-based holistic health and social care plan in conjunction with medical/other health professionals and social care colleagues. To provide co-ordination of clinical case management for complex and frail patients and those with long term conditions, who are at risk of declining clinical quality of life or avoidable hospital admission. To discuss assessment outcomes with patients, carers, their GPs, and other health and social care professionals. To liaise closely with other health and social care professionals to provide community care and support to meet the needs of an individual. To identify social isolation and loneliness, being proactive in sign-posting to relevant resources to empower patients to remain active and engaged within their communities. Work closely with the social prescribing team. Using a high level of communication and interpersonal skills, establish effective working relationships with patients, their families, and carers. To recognise and identify a deterioration in an individual’s health and act promptly to reduce the risk of rapid deterioration or where appropriate avoid hospital admission. Refer on to relevant health professional as required. To educate individuals and carers/relatives to identify early warnings of deterioration in order to facilitate rapid management of complications or crises. To facilitate early discharge, where possible, from hospital for case managed patients by co-ordination of care and services to be delivered within primary care/community. To identify those individuals with more complex health needs and refer for a holistic, multi-dimensional, interdisciplinary assessment with members of the MDT specialising in older people's health and/or specialising in long term conditions, to include appropriate specialist secondary care expertise. To participate in the MDT meetings, where appropriate identify patients that may require an MDT review. Person Specification
Qualifications
Essential Registered Nurse Desirable Mentorship Qualification Post Graduate qualification Experience
Essential Previous experience working in primary/community care setting or working in a relevant secondary care role i.e. Care of the Elderly Experience of working under own direction Ability to self-motivate, organise, and prioritise workload Desirable Experience of supporting service improvement Experience at supporting peers, new learners, and mentoring junior colleagues Personal Qualities and Attributes
Essential Excellent written skills and a high level of verbal communication skills Demonstrates compassion and understanding of holistic, patient-centred care Ability to use own initiative and recognises own scope limitations Demonstrates team player qualities Information Technology
Essential Evidence of working with IT systems including Word, Access, Excel Ability to handle sensitive information confidentially, full awareness of data security Other
Essential Subject to the provisions of the Equality Act, able to travel using own vehicle on Network business
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To work as a member of the Poole Central Primary Care Network Enhanced Care Team to coordinate clinical case management for frail and complex patients and those with long term conditions who are at risk of further deterioration in health or an avoidable hospital admission or unnecessary length of hospital stay. To be responsible for a caseload of patients who have either been identified using an agreed case finding tool (Electronic Frailty Index or Rockwood) or whom have been identified by another healthcare professional as frail or as having a long-term condition. As part of a team approach, to be responsible for identifying an individual’s principal needs through a holistic, comprehensive assessment, develop care plans, and work closely with other members of the MDT and primary care/community care team to support patients in the community. To support preventative care, screening, and patient education to enable the patient to manage frailty and long-term conditions. To be adaptable and able to work across all aspects of the service, including where needed, supporting the Care Home and Acute home visiting services. About Us
Poole Central PCN is the second largest PCN in Dorset and one of the first to develop an operational Hub with a central co-ordination team and clinical teams co-located in a dedicated building. The PCN services comprise a multi-professional Enhanced Care Team, responding to the needs of the population who are housebound or living in long-term residential care. The ECT comprises ANPs, RNs, HCAs, Paramedics, Specialist Diabetes and Respiratory Nurses, and Clinical Pharmacists, working together to optimise clinical outcomes and support people to remain living independently whenever possible and working closely with Practice Teams to ensure effective co-ordinated care. We work collaboratively with partners in health and social care and are currently developing a number of pathways that involve models of integrated working, and information systems and digital technology have a key part to play in achieving greater efficiency in how we work. The post-holder will be employed through The Adam Practice (Lead Practice) on behalf of the PCN and details of Terms and Conditions of employment are available on request. Job Responsibilities
To undertake a holistic full assessment of the physical and psycho-social care needs of complex and frail patients and those with long term conditions, involving carers and relatives. To establish an individual’s functional capabilities with regards to frailty, as well as ability to manage other long-term health conditions. To provide cognitive assessment and identification of mental health needs, referring as appropriate. To identify an individual’s principal needs and support them in the development of plans to address related issues, supporting self-management where feasible. To develop a person-centred, evidence-based holistic health and social care plan in conjunction with medical/other health professionals and social care colleagues. To provide co-ordination of clinical case management for complex and frail patients and those with long term conditions, who are at risk of declining clinical quality of life or avoidable hospital admission. To discuss assessment outcomes with patients, carers, their GPs, and other health and social care professionals. To liaise closely with other health and social care professionals to provide community care and support to meet the needs of an individual. To identify social isolation and loneliness, being proactive in sign-posting to relevant resources to empower patients to remain active and engaged within their communities. Work closely with the social prescribing team. Using a high level of communication and interpersonal skills, establish effective working relationships with patients, their families, and carers. To recognise and identify a deterioration in an individual’s health and act promptly to reduce the risk of rapid deterioration or where appropriate avoid hospital admission. Refer on to relevant health professional as required. To educate individuals and carers/relatives to identify early warnings of deterioration in order to facilitate rapid management of complications or crises. To facilitate early discharge, where possible, from hospital for case managed patients by co-ordination of care and services to be delivered within primary care/community. To identify those individuals with more complex health needs and refer for a holistic, multi-dimensional, interdisciplinary assessment with members of the MDT specialising in older people's health and/or specialising in long term conditions, to include appropriate specialist secondary care expertise. To participate in the MDT meetings, where appropriate identify patients that may require an MDT review. Person Specification
Qualifications
Essential Registered Nurse Desirable Mentorship Qualification Post Graduate qualification Experience
Essential Previous experience working in primary/community care setting or working in a relevant secondary care role i.e. Care of the Elderly Experience of working under own direction Ability to self-motivate, organise, and prioritise workload Desirable Experience of supporting service improvement Experience at supporting peers, new learners, and mentoring junior colleagues Personal Qualities and Attributes
Essential Excellent written skills and a high level of verbal communication skills Demonstrates compassion and understanding of holistic, patient-centred care Ability to use own initiative and recognises own scope limitations Demonstrates team player qualities Information Technology
Essential Evidence of working with IT systems including Word, Access, Excel Ability to handle sensitive information confidentially, full awareness of data security Other
Essential Subject to the provisions of the Equality Act, able to travel using own vehicle on Network business
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