Job Description

Provide same-day home visits to patients at risk of hospital admission. Conduct comprehensive assessments for patients who require admission prevention support. Perform clinical assessments, diagnoses, and treatment plans, ensuring safe and effective care. Work autonomously while collaborating with GP practices, Community Medical Teams (CMT), Urgent Community Response (UCR), and District Nurses to ensure joined-up care.



Identify patients who may benefit from Virtual Ward input or MDT frailty discussions to optimize their care. Use critical thinking and clinical decision-making to provide safe, evidence-based interventions. Provide a clinical initial triage/assessment of all inbound referrals and identify the most appropriate disposition/timeframe & to identify the most appropriate MDT clinician. To prioritise health problems and intervene appropriately to assist the patient in complex, urgent or emergency situations, including the initiation of effective emergency care.



To work autonomously & demonstrate safe, clinical decision-making Carry out proactive holistic assessments to create care plans to help reduce risk of future hospital admission. To assess, diagnose, plan, implement and evaluate treatment/interventions and care for patients presenting with an undifferentiated diagnosis. Attend Local Multi-Disciplinary meetings and present Patient cases. Demonstrate clinical expertise and act as a professional role model to all colleagues, both internal and external on behalf of SDHC, working as part of an integrated team taking the lead and developing services in line with the needs of the patient To ensure that accurate and complete records of care are kept and that your own practice and practice of other team members is compliant with agreed policies, procedures, guidance and legislation in order to deliver effective patient care.



To develop close links with the wider community to enhance both care for individual patients and the wider development of Surrey Downs Health and Care. Treat all patients as individuals, respecting their privacy and dignity at all times Involving, supporting, informing and educating family/carers. Promote the health of patients and the provision of support and advice. Be responsible for ensuring that policies and procedures and standards of care, are adhered to at all times Have the ability to negotiate and work effectively across all agencies for the maximum effectiveness of care Contribute to the development of integrated care in the community.



Be aware of and act upon when necessary, procedures that are in place to protect vulnerable individuals Maintain own professional and clinical integrity in line with NMC/HCPC guidelines Undertake any other such duties as may be required from time to time as are consistent with the responsibilities of the post. Be responsible for individual timely data entry and responsible for the corporate teams data entry Employees are employed to work within SDHC localities and may be reasonably requested to move base temporarily or on a more permanent basis, as requested by service needs. Ensure all Statuary and mandatory training is kept up to date. This job description is subject to review and development from time to time in liaison with the post holder.



As an employee of SDH&C you will be required to adhere to all the organisations policies and procedures