Role Description

The post holder will proactively manage a caseload of patients requiring complex case management in order to prevent hospital admissions and facilitate early discharge to improve patient health outcomes. Patients requiring case management in the H@H AND UCR Service will be identified by case-finding in the Ambulatory Emergency Care (AEC) unit, Accident and Emergency Department, Whittington Health wards, North Middlesex Hospital A&E, ULCH @home, LAS, Care Homes, Community Nurses and via GP referral.

Patients will be identified as not requiring hospital admission but need high acuity Community support to go home safely.

Responsibilities

• Working autonomously, the post holder will have continuing responsibility for proactively monitoring and managing patients on the caseload.
• The post holder will be expected to develop skills in physical assessment, diagnostic reasoning and nurse independent prescribing and use these both in the community and ambulatory care centre setting.
• Using these skills will assist in the recognition of early symptoms of disease exacerbation, acute illness and injuries.
• The post holder will be expected to co-ordinate care and navigate the patient through pathways across the primary, secondary care interface, including the prevention of unnecessary admissions, facilitating appropriate ones through in-reach case finding in both the hospital settings also via Community referral.
• Facilitate the early discharge of patients from the Whittington Health and NMUH inpatient wards and complete their recovery in the home environment by working collaboratively with the AEC Consultant.
• Be aware of and utilise appropriate resources within the H@H AND UCR team and in the provision of total patient care.
• Managing the team on a day-to-day basis, supporting junior staff with decision making and skills development.
• Undertake a comprehensive baseline assessment for each identified patient in conjunction with the AEC consultant, patient, relatives, carers and patient care team.
• Use the assessment to agree and implement a patient held personalised plan of care to be agreed with the patient, relatives and carers and the patient care team.
• Ensure that there are effective communications with other agencies about care plans to support patients at home.
• Undertake prescribing as required and to ensure that medications are reviewed and highlight possible interactions and changes.
• Perform and document examinations to support proactive monitoring of chronic diseases and identification of early symptoms of exacerbation and liaise with the MDT.
• Work with the AEC consultant, ward consultants and/or General Practitioner and patient care team to facilitate this and reduce hospital admission.
• Lead by personal example of best infection control practice at all times.