Job Description

This role is offered on a fixed term/secondment basis for 6 months. The hours are 37.5 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 Matron/Clinical Case Manager assumes the role of an autonomous Clinical 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 manage patients with long-term conditions and at risk of deterioration, including those with frailty. The Community Matron/Clinical Case Manager provides comprehensive and specialised support to patients, carers, and families, enabling them to lead fulfilling lives alongside their conditions. They employ motivational interviewing and health coaching to establish therapeutic relationships, thereby mitigating unplanned hospital admissions. This proactive strategy fosters improved health outcomes.



The Community Matron/Clinical Case Manager works 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.

Triage:

Ensure patients meet the criteria for the service.

Holistic Assessment:

Within a patient's home environment, conduct a comprehensive assessment.

Risk Assessment:

Evaluates patients' safety needs to determine the most appropriate care setting. This involves providing specialist advice and, if necessary, signposting or referring to other healthcare providers.

Medication Assessment and Review:

Assess and review medication for therapeutic effectiveness, prescribing, and/or de-prescribing in accordance with evidence-based practice, national and local protocols, and within the scope of practice and legislative framework.

Collaborate with other prescribers (GPs, pharmacists, consultants, and specialists) to ensure continuity and safe prescribing practices.

Case Management:

Identify, prioritise, and implement case management plans to achieve health gains and maximise patient independence.

Maintain effective and timely communication with patients, carers, and all relevant services and agencies (statutory and non-statutory).

MDT Meetings:

Attend, participate, and lead where appropriate weekly internal MDT meetings and external meetings as required.

Provide clinical supervision to Health 7 Wellbeing Coordinator and as a line manager, have the responsibility of signing off expenses and annual leave according to Trust policy.



The qualification, training & experience requirements for the role are underlined in the /Person Specification.



We have a skilled and dedicated workforce of over 5000 colleagues working in a diverse range of services over 55 sites and within people's homes. We strive to enable a welcoming workplace culture that builds and celebrates civility, inclusivity and diversity, while providing a sense of belonging and trust.



Annual staff surveys, regular Pulse surveys and other engagement opportunities provide our people with lots of opportunity to tell us about their experiences of working with us. In the latest staff survey, 61% of colleagues gave us their views. It was great to hear that:



72% of colleagues would recommend the Trust as a place to work, ranking us 1st for Provider Trusts in the South West region on this question.



76% would recommend the standard of care provided in our services if a friend or relative needed treatment, also ranking us 1st in the South West region.



81% said that care of patients and service users is the Trust's priority, compared with an average in comparable NHS Trusts in England of 64%.



This high-level overview shows we are in a healthy position, with higher scores than average for comparable organisations, alongside a great response rate, indicating good staff engagement. However, we also know we have plenty of room for improvement in many areas. To that end, we continue to prioritise and invest in our commitment to genuinely becoming a Great Place to Work with consistent top-quartile performance in the annual staff survey and Pulse surveys.



Work with other members of the team to organise workload, work flexibly with team members across the County to cover the service

The post holder will mainly communicate face to face with patients in their own homes whilst undertaking assessments. There will also be follow up telephone calls and letters when required.

There may be times when the post holder will have to adapt their communication style to the audience when patients have difficulty in understanding.

The post holder will be highly skilled in communicating effectively and be able to deal appropriately with complex and sensitive information.



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