Job Description

To hold a small, complex, clinical caseload that will include undertaking generic and specialist assessments of patients with diverse and complex physical conditions, providing a clinical diagnosis and delivery of individualised recovery programmes. The caseload will include patients requiring chronic disease management as well as support to avoid admission to hospital and on discharge from hospital due to acute medical change. To support the recovery process by providing expert clinical advice and recovery to patients with multiple long term conditions living in the community who are at risk of deteriorating health that may result in declining quality of life or avoidable hospital admission or an unnecessary longer length of stay. Provide high level assessment to establish most appropriate intervention, balancing clinical and managerial responsibilities to the service.



Ensure a high standard of clinical care for all patients and to support, facilitate and develop less experienced staff to do likewise. Undertake comprehensive assessment of patients including those with diverse and highly complex presentations and multiple pathologies, using advanced clinical and analytical skills to provide an accurate assessment of their condition. Assess the physical and psychosocial needs of a defined client group. Maintain a patient focus and ensure that patient experience is listened to and valued.



Discuss all recovery options with sensitivity, knowledge and expertise and to act as patient advocate when appropriate and respecting patient confidentiality with privacy and respect for diverse cultural backgrounds and requirements. Provide individualised recovery plans for patients with highly complex multi-factorial long term conditions, so that their condition remains as stable as possible and, where appropriate, hospital admission is prevented and early discharge facilitated. Analyse complex patient situations establishing a therapeutic relationship in which they are able to utilize counselling skills to assist the individual to adjust to their illness and care For more information please see attached job description and person specification