Community Matron / Clinical Case Manager

Job overview

This post is part time 28.75 hours per week.

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.

Complex Care at Home is an established and innovative complex case management service that currently serves Gloucester, Cheltenham, and the Forest of Dean localities, with an aim to roll out across countywide.

The service collaborates closely with acute settings, community teams,

social services and primary care to identify and support patients who

would benefit from a case management approach.

Through a collaborative approach, the team works with patients

families, and carers, employing a coaching methodology to facilitate

problem-solving and empower self-management.

Each patient is assigned to the Complex Care at Home Team for a

specific period before being appropriately discharged.

Job description

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.

Job responsibilities

Triage Process: Ensure patients meet the criteria for the service.

Holistic Assessment: Within a patients home environment, employs advanced and specialised skills to conduct a comprehensive assessment of their clinical, physical, psychosocial, and spiritual needs.

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. Assesses care plans, develops, implements and evaluates specialised programmes of care/ care packages.

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.

The Trust is required to work in line with the Governments UK Visa and Immigration Rules and Regulations. For more information about sponsorship for certain roles, please visit - https://www.gov.uk/browse/visas-immigration/work-visas

To support compliance with UK immigration requirements, all applicants who require a visa to work in the UK must disclose their visa history in full. This includes current and previous sponsors, dates of sponsorship, visa category, and any changes of employment. If you are on a Graduate or Dependant Visa, please disclose the expiry date on your application. Incomplete information may mean we are unable to consider your application.

About the organisation

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.

Person specification

Qualifications

Essential

• Level one Registered General Nurse or Allied Health Care Professional
• Professional knowledge acquired through degree supplemented by post graduate diploma specialist training, experience, short courses plus further specialist training to masters equivalent level or equivalent.
• Current and valid registration with the relevant professional body
• Evidence of post-registration qualifications/experience at post graduate level in managing complex long-term conditions and frailty.
• Qualification in Physical Assessment and Clinical Reasoning (PACR)
• Facilitating Learning and Assessment in Practice qualification (FLAP) or equivalent Qualification
• Academic qualification at degree level or above in a variety of long-term conditions with evidence of experience in case managing long term conditions

Desirable

• Independent Non-Medical Prescribing

Experience

Essential

• Experience in managing a complex clinical caseload
• Experience in managing difficult situations that require advanced communication and negotiating skills
• Experience in managing clinical risks
• Experience of case management models of care including personalised goal setting, care planning and self-management plans and escalation plans
• Evidence in advanced comprehensive assessment including interpreting information, performing clinical interventions, diagnostics and analysing results.

Desirable

• Significant post registration experience spent in a variety of settings including the community

Skills and Attributes

Essential

• Broad understanding of different models of case management across professional groups
• Have a good understanding on ways to identify patients who would benefit from case management using a variety of resources.

Supporting documents

• Community Matron Clinical Case Manager PS.pdf (PDF, 145 KB)
• Community Matron Clinical Case Manager JD.pdf (PDF, 233 KB)