Integrated Care Lead inGreat Yarmouth inGreat Yarmouth PUBLISHED FRI 22 NOV 2024

East Coast Community Healthcare CIC (ECCH) is commissioned to provide Community healthcare services to our local communitiy, this role is central in ensuring optimum patient outcomes and developing effective relationships with staff from other organisations and local health care providers.

Does this sound like something you would like to be a part of? Do you have a Can do attitude? Are you ready to shape and make real our aspirations for innovative, integrated healthcare, which will improve the health and wellbeing of our communities? Then we need you.

We are seeking an Allied Health Professional or Registered Nurse (Adult) to lead and manage the reablement element of our Primary Care Home, in order to deliver high quality community health care to the population of Gorleston & Great Yarmouth. If you are a compassionate, innovative, motivated and forward thinking clinical leader, then this could be the job for you.

Previous experience of providing health care in the community, rapid response, case management and people management would be beneficial. We will support the right candidate to transfer existing knowledge and skills as a registered AHP/Nurse working in a different care environment. We will work in partnership with you to create a personal development plan to become a PCH Integrated Care Lead.

The role requires a high level of autonomy as the Integrated Care Lead for the PCH you will be coordinating complex packages of healthcare, overseeing the delivery of reablement care by the multidisciplinary team, supporting the PCH response for Admission Avoidance, providing line management to a number of clinical employees. You will be working in close collaboration with the Lead Nurse, Lead Therapist, Community Matrons and Locality Lead to provide clinical leadership within the PCH. Confidence is needed to provide the team with support and guidance regarding patient care, staff development and delegation. Close links are developing with the acute and community hospitals to ensure care is provided in the best place for the patient and as an Integrated Care Lead you will be at the forefront of integration and development of these changes. This will include oversight of the assessment of patients suitable for discharge from the acute hospital.

The PCH is commissioned to provide a 24/7 service. The core shift is currently 08:30 to 16:30 hours. Applicants may be required to participate in working other shifts as part of the role including weekend and bank holiday working on a rotational basis.

About us

We Listen, We Learn, We Lead

• Contribute to, support and promote ECCHs strategic direction, values and culture in relation to Reactive services.
• Discuss all treatment options with sensitivity, knowledge and expertise and to act as a patient advocate when appropriate, respecting patient confidentiality with privacy and respect for diverse cultural backgrounds and requirements.
• Understand and support the achievement of ECCH business plan objectives and performance targets for team and self, and initiate and participate in screening and needs assessment as required.
• Identify the potential for service developments, risk and deficits and inform line manager making recommendations based on specialist knowledge and experience.
• Provide leadership and ensure effective management of integrated teams, including rehabilitation support workers and paramedic teams through identified and those providing a Reactive response.
• Plan and organise a range of complex integrated multidisciplinary coordination in a wide range of settings to ensure best practice is delivered across the designated area of responsibility and the wider community.
• Provide clinical leadership within the integrated care coordination team including Primary, Social Care, and all other provider organisations to ensure high standards of care to patients the avoidance of unnecessary admission to secondary care.
• Through effective leadership, planning and coordination; be a key enabler for establishing integrated care teams both practically and behaviourally.
• Work with the Primary Care Home leadership team (Locality Leads) to design, implement and review pathways and guidelines to support health care professionals in establishing patients to access evidence-based therapies.
• Develop systems to monitor, evaluate and audit service quality in order to meet nationally and locally set targets and report to Locality governance groups.
• Effectively communicate at all levels of the organisation and wider stakeholder, including a variety of health professionals, users and carers, to provide the best health outcomes.
• Maintain high levels of performance for service area and ensure that goals and objectives are monitored effectively to ensure quality outcomes are developed and maintained.
• Provide leadership and manage stakeholder relationships effectively within service area and ensure teams and individuals are supported when faced with opposition or when working under conditions or pressure.
• Identify potential service developments, risks and deficits and discuss with line manager, making recommendations based on expert knowledge to enhance the capacity and quality of community care.
• Monitor and maintain standards/provide benchmarking data within service area to allow comparison with other healthcare providers.
• Participate in teaching and clinical supervision with primary care home team and other provider staff as required.
• Critically evaluate research findings, national guidelines and implement changes in clinical practice as appropriate.
• Signpost patients, families, and carers to tailored education programmes, advice and support that may precipitate symptoms of acute exacerbation of underlying conditions or illness and include lifestyle changes that would be advantageous to health.
• Be responsible for participating and maintaining a learning environment and maximise opportunities for education and development in the clinical area to enhance individual development and performance in the delivery of high standards of care.

My Accountability, My Responsibility

• Take responsibility for own personal and professional development; maintain competence, knowledge and skills commensurate with role.
• Using a standardised approach but with a high degree of professional autonomy and accountability, work with Health, Social Care, Voluntary and other health providers and agencies, to provide patients with complex needs a single plan of care co-produced with the patient.
• Responsible for ensuring effective patient/case tracking within the local health system; provide baseline health data for receiving teams to support integrated, coordinated care. To include facilitation of Community Led discharge processes.
• As Care Coordination Lead, ensure high visibility and be accessible to patients, families and carers and be seen as being in charge of their care.
• Use assessment tools/skills that will ensure an appropriate level of nursing or therapeutic intervention so that patients who present with highly complex needs are timely referred to the appropriate specialist.
• Be wholly accountable for practice taking every reasonable opportunity to sustain and improve knowledge and professional competence and, ensure that all aspects of professional behaviour as required within professional code are followed at all times.
• Maintain legible, accurate and contemporaneous patient records in accordance with ECCH Policy; the Nursing and Midwifery Council and Health and Care Professionals Council standards for record keeping.
• Assist with the investigations of complaints, participate in the risk management process, critical incident reporting, evaluation, dissemination and change in practice.
• Be responsible for understanding, following and implementing ECCH policies and procedures, and influencing working practices to support this accordingly.
• Contribute to the clinical governance agenda through participation in clinical risk assessment and management, clinical audit.
• Create an environment conducive to effective working, respecting and supporting staff to deliver high quality clinical services.
• Ensure a high standard of record keeping is achieved in line with ECCH and professional standards.
• Take responsibility to ensure compliancy with Health and Safety Policy, Fire and Environmental Waste Regulations.

Respect Our Resources: People, Time and Money

• Take responsibility for the cost-effective management and safe use of expensive and highly complex equipment, provide recommendations for effective use of resources and contribute to the effective delivery of cost improvement planning.
• Analyse, interpret, compare and contrast complex information, service requirements and options ensuring the effective approaches to service delivery and team working within service area.
• Evaluate the impact of Health Coaching programmes designed for patients and carers, to ensure that they provide the necessary knowledge and skills to gain independence, safely manage changing circumstances and plan for unavoidable progression of conditions.

Work Together, Achieve Together

• Using generalist clinical skills to evaluate the delivery of care, identifying subtle changing health care needs. Being able to discuss treatment options with other generalists and specialists.
• Co-ordinate care across the whole patient pathway in ECCH for service area. This includes ensuring a robust relationship and ongoing effective interface with ECCH specialist services, primary and secondary care as required.
• Working with partners in Primary and Social care to support a model of care which identifies and case manages those patients needing complex chronic disease management or palliative care supporting the needs of the local community.
• Negotiate and agree with the patient carers and other healthcare professionals, individual roles and responsibilities with actions to be taken and outcomes to be achieved, referring on to other services or professionals as appropriate.
• Work in partnership with the patients to empower them to make informed choices about their healthcare and support choices about end of life care.
• With peers, and under the supervision of the Locality Lead, establish local networks in partnership with other health and social professionals/agencies and national links with other generalists in order to develop protocols according to national and local guidelines for the safe and effective provision of a community nursing services.
• In partnership with Primary Care colleagues provide seamless care pathway for patients who occupy the Beds with Care.
• Work with partners in nursing and residential care to improve the health outcomes of the residents and so prevent unnecessary hospital admissions or extended in- patient care episodes.
• Provide professional expertise and clinical leadership within service area, acting as a resource to other professionals internally and outside ECCH, concerning clinical caseloads to ensure continuous service provision, high levels of communication and effective inter-professional working.
• Work with ECCH Colleagues, and other partner agencies and stakeholders including the acute trust to contribute to the development and delivery of new innovative models of service delivery, ensuring a leading edge approach to service development in-line with evidence based practice.
• All roles within East Coast Community Healthcare CIC (ECCH) require staff to demonstrate our Values and Signature Behaviours in the care and service they provide to patients, service users, stakeholders and colleagues. All members of staff should consider these as an essential part of their job role.
• Our Values outline the core behaviours that we can all achieve and are summarised as an acronym within the word CARE. These stand for: Compassion, Action, Respect and Everyone.
• Underpinning our Values are our Signature Behaviours which highlight by taking the right actions we continue to build a strong culture. Our four Signature Behaviours are: Compassion - We Listen, We Learn, We Lead| Action - My Accountability, My Responsibility | Respect - Respect Our Resources: People, Time and Money | Everyone - Work Together, Achieve Together.