Key responsibilities include conducting holistic assessments, developing individualized care pathways, communicating sensitive information to patients and their families, and collaborating with various healthcare professionals to coordinate seamless care. The nurse will also participate in triaging referrals on a rotational basis and be involved in multidisciplinary meetings to integrate services effectively. This position entails working as part of a 7-day a week service from 8 am to 8 pm, requiring some weekend availability.
To lead in the delivery of high standards of health care to patients within their own place of residence by assessing, planning, implementing, and evaluating care in order to prevent avoidable admission to hospital and facilitating early supported discharge.You will be expected to lead conversations with the wider Urgent Community Response (UCR) Multidisciplinary Team (MDT) on a regular basis enabling safe, appropriate and patient centred care to be delivered to this complex patient group.
This role will predominantly involve face to face nursing care and assessment within a patient's usual place of residence, with an element of Triage for the Urgent Community Response Team on a rota basis plus other supportive activities as part of the Multidisciplinary Team.This is a 7 day a week service and some weekend working will be expected. Hours of service delivery are 8am-8pm 365 days per year
As part of the Urgent Community Response Team you will be required:o To work within the Urgent Community Response Team to prevent unnecessaryadmission to hospital.o To assess and prescribe care pathways for patients in a crisis situation with long term conditions, the frail & elderly, palliative and end of life care and/orrehabilitation needs, to achieve quality of life and independence plus prevent avoidable admission where possible.o To act as the patients advocate, facilitating choice and patient empowerment.o To provide evidence based clinical/therapeutic interventions based on "best practice".o To work within the Urgent Community Response Team to support earlydischarge from hospital.o To work with all health care professionals, and statutory/non statutory agenciesto provide a seamless, integrated service to our service users.o To triage referrals on a rotational basis for the Urgent Community ResponseTeam.
About us
The post holder will:1. Assess, plan, implement and evaluate all aspects of patient care, and developtreatment/care pathways that may need to be delivered from a range of options.2. Follow a holistic assessment, devise an individualised care pathway for eachpatient, modifying it as required.3. Be aware of Assistive Technology and utilise where required.4. Assess patients holistic needs, communicating complex and sensitiveinformation to patients and carers as to their assessment, diagnosis, prognosisand treatment plan.5. Where there are barriers to understanding, such as hearing impairment, mentalcapacity impairment and other difficulties in comprehension, explanationsrequire adjustments in order to gain understanding, consent and concordance.6. Establish and maintain therapeutic relationships with patients and carers,incorporating motivation, encouragement and confidence building to enablepatients to engage in their treatment/care/management plan.7. Liaise with GPs, Social Services, inpatient teams, other allied health careprofessionals and the voluntary sector to ensure identified needs are met andcare co-ordinated appropriately.8. Be required to undertake risk assessments and act upon them appropriately.9. Participate in multi-disciplinary/multi-agency meetings as appropriate, e.g. GoldStandard Framework.10.Plan and organise specialist services within the Urgent Community ResponseTeam.11.Ensure activity data and clinical information is recorded on SystmOne andcompleted on a daily basis.12.Demonstrate dexterity and co-ordination when using specialist equipment andfine tools, advanced sensory skills, manual and mobilising skills.
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