Job Description Job Title Community Matron Salary Band Band 7 Division/Service Line Adult Community Services Department Integrated Care Job Overview The purpose of the post is: • To take a lead role in the development of primary care for older people with multiple chronic diseases who are at high risk of hospital admission, through proactive management of a high- risk caseload and focussing on ways to demonstrate overall improvements in health care. To work collaboratively with the multidisciplinary team to establish a whole systems approach to managing health care for these individuals. Key Dimensions of the post are: • The nurse is based in General Practice and has overall responsibility for a caseload of 50-60 patients who require intensive support and management and who meet the following criteria: Has two or more emergency admissions to hospital in the past year Suffer from chronic disease Take 4 or more medications The nurse works within the community nursing service and is responsible for provision of evaluation data & promotion of the service within her area of expertise. The nurse is responsible for management of resources within her caseload & area of practice. Main tasks are to: • Act as “case finder” identifying patients with multiple chronic diseases within a practice population who are at high risk to numerous admissions to hospital and admitting them to the Community Matron’s caseload. • Managing patients with chronic disease through advanced level autonomous practice including taking managed risks. For example where the patient is kept at home, rather than hospital admittance as would previously been the practice. • Take clinical responsibility for the patient and work collaboratively with all professionals, carers and relatives to gain a deep understanding of all aspects of the patient’s physical, emotional and social situation. This includes physical examination and detailed history taking, diagnosis and treatment planning. JD No: 201-19-314 • Act as commissioner of care and services to meet patient’s needs including advising expenditure of devolved intermediate care budgets. • Develop a personalised care plan for the patient based on the full assessment of medical, nursing and care needs. This includes preventative measures and anticipation of future needs. • Ensure regular personal contact with the patient, monitoring their condition regularly and diagnosing deterioration in condition that may lead to hospital admission without intervention by the Community Matron. • Order investigations and tests and interpret and act on results, using clinical guidelines and policies to support clinical decision-making. • Maintain competence in prescribing according to level of prescribing qualification i.e. Nurse Prescriber or Independent Prescriber and participate in regular continuing professional development in relation to the role. • Prescribe medication within nurse prescribing formulary if appropriate. If qualified as an Independent Prescriber, prescribe in accordance with the local Non-medical Prescribing Policy, Cornwall and Isles of Scilly Formulary and local and national prescribing guidance. It is expected that all prescribers will prescribe within the limits of their individual competence. • Update the patient’s medical records using Community Matron patient record and on GP’s computerised systems. • Liaise with other local agencies to mobilise resources to meet patient needs and to support them at home securing additional support as required in acute episodes. • Teach patients and carers to recognise subtle, often hidden, changes in condition that could lead to deterioration in their health and when to call for help, acting as first point of contact for the patient when deterioration occurs. • Maintain contact with the patient if he/she is admitted to hospital, providing information about home circumstances to the hospital staff and ensuring that discharge of the patient is rapid, planned and safe. • Act as a resource for other community team members, providing teaching and education to them as required. • The Community Matron has a responsibility to participate in the evaluation of the service and service development, plus research and development relating to the evolving Community Matron role nationally. Organisational Chart Locality Director Integrated Care Manager CMs throughout Cornwall Community Matron (this post) JD No: 201-19-314 Duties and Responsibilities Knowledge, Skills, Training and Experience: The post holder is required to be a Registered Nurse with substantial experience in the management of long term conditions, managing complex needs and holding advanced clinical assessment skills. The post requires the completion of the HEAB 358 Advancing Practice in Long Term Conditions Management module or the equivalent. The post holder should be an independent prescriber or working towards this qualification Autonomous Clinical Practice: To take a comprehensive history, perform a systematic physical examination and establish baseline data to inform the development of a comprehensive care plan. Analyse signs and symptoms, laboratory tests, investigations and other measures of function in formulating a diagnosis. Provide evidence-based treatment plans based on sound clinical decision making, including the unique presentation of illness and response to treatment of elderly people and those with chronic disease. Collaborate with GP/Hospital Consultant to plan and implement treatment for acute illness/injury/chronic illness as required, using skills in nurse prescribing and medicines management. Monitor indicators of chronic disease, anticipating possible decline and proactively managing this to enhance well-being and promote independence. Plan interventions in light of patients’ express wishes and goals of care, facilitating discussion with the family and significant others. Ensure a robust process is in place to review care and treatment plans Take an active role in auditing and monitoring all components of care delivery. Review and develop clinical competency as required to support clinical practice, participating in ongoing personal development. Ensure all clinical records are kept in line with NMC guidelines. Care Co-Ordination: Integrate care across all care settings; preventing duplication, fragmentation and delay occurring as patients move between care settings. Build relationships across professional and organisational boundaries, breaking down barriers and smoothing the patient’s journey. Negotiate with other professionals in all settings to provide care in the most appropriate and least invasive manner possible. Participate as a key member of the multidisciplinary team through development of collaborative and innovative practice. Communication: Establish the dynamic process of understanding, reflecting, active listening and checking understanding, thus developing a therapeutic relationship with patients and their carers. Enable and support patients as active partners in the care planning process for present and future needs. Dissemination of information throughout the multidisciplinary team, taking into account the patient’s right of confidentiality. Education: Utilise communication skills and knowledge to promote patients and families abilities to make JD No: 201-19-314 informed decisions and participate in care planning. Empower patients and carers to evaluate possible treatment options as disease progresses and evaluate the relative benefits and burdens of these treatment options. Participate in the development of the teams’ knowledge about disease, disease processes and treatments. Play an active role in disseminating knowledge about chronic disease and its management within primary care, mentoring students as required and developing education for other primary care colleagues. Provide and create learning opportunities in the clinical setting that support the wider primary care team. Continue to develop own expert practice. Critically evaluate research and integrate theory into practice. Leadership/Management: Contribute to the development of policies, procedures and guidelines ensuring they are implemented and monitored. Participate in the appraisal process, providing feedback on performance. Contribute to the recruitment and selection process. Act with colleagues to identify clinical development needs within the service. Act as an advocate at all times for both patients and the service. Play an active role in raising public awareness of the needs of people with chronic disease, in particular, older people. Professional: Work within the NMC Code of Conduct. Remain updated and ensure that clinical practice is evidence based. Have a personal development plan and professional portfolio. Freedom to Act: The post is a clinically autonomous one and the post holder is expected to manage their caseload and the care of their patients independently recognising the limits of their knowledge and experience and seeking help and support appropriately Working Conditions • Based within the DN Team, but working mainly in patient’s homes. • Carrying light cases and other equipment. • Some computer based work and data inputting. • Car driving. • Not required to wear uniform. • Expected to deal with difficult situations on a regular basis. • Working in patients own homes JD No: 201-19-314 Additional Information Code of Conduct The post holder is required to comply with all relevant Code of Conducts for the role, including the Trusts Code of Conduct. All staff are