In this role, the practitioner will lead clinical initiatives, support integrated care pathways, and engage with primary and social care providers to address the needs of patients with complex conditions. They will maintain high standards of clinical practice in accordance with relevant regulatory frameworks and Trust policies, manage referrals autonomously, and establish partnerships with other health and social professionals to enhance service delivery. Additionally, the role requires critical analysis of clinical data to inform diagnoses and promote better health outcomes in the community.
To work within the integrated 'Acute care at Home' integrating rapid response with our Virtual Ward service supporting the provision of enhanced care in the community, reducing avoidable attendance and admission to secondary care, and supporting early discharge. This will be achieved by utilising expert clinical assessment and diagnostic skills in the management of patients who require an urgent assessment. To be a key member of multi-disciplinary team and identify optimal pathways for patients, utilising community capacity, skills, and experience, to ensure care is provided at the right time and in the right setting.
This service will be transitioning to HCRG Care Group from the 1st April 2025. The successful candidate may transfer over (under Transfer of Undertakings (Protection of Employment) Regulations 2006) on the terms and conditions they are employed on. Great Western Hospitals NHS Foundation Trust is committed to ensuring a smooth transition for everyone involved.
1. The post holder will be able to combine high level assessment to establish differential diagnosis and clinical decisions to initiate medical and/or nursing/therapy treatments, appropriately refer and lead the co-ordination of care from an integrated team perspective, working with partner agencies and key stake holders.
2. To be a key driver for change to assist integrated care pathways/systems across GWH services and system partners.
3. To provide clinical and professional leadership within the acute care @home service supporting the wider community including Primary Care, Social Care, and all other provider organisations to deliver high standards of care to patients. Where appropriate this will be the avoidance of unnecessary admission to secondary care. To be an integral member of the multidisciplinary team working with a shared vision in partnership with each other.
4. Draw on clinical knowledge to be a resource for the wider multidisciplinary team (MDT) and give clinical advice.
5. To work in alignment with Primary care around established practice populations and to facilitate the establishment of a shared vision between Primary care and the Community teams.
About us
1. Working with partners in Primary and Social care further develop a virtual ward model/Urgent communityresponse which identifies, and case manages those patients needing complex chronic diseasemanagement or palliative care supporting the needs of the local community.2. Maintain accountability for practice following the Nursing and Midwifery Council Code of ProfessionalConduct/Health and Care professions Council Standards of conduct Performance and ethics and compliancewith Great Western Hospitals NHS Foundation Trust Policies and Procedures.3. Maintain legible, accurate and up to date records that are dated and signed in accordance with Trust Policiesand the Nursing and Midwifery Council / Health and Care Professions Council standards onrecord keeping.4. Work autonomously with patients, their families and carers managing referrals according to need andpriority.5. Negotiate and agree with the patient, carers and other care professionals, individual roles, and responsibilitieswith actions to be taken and outcomes to be achieved, referring on to other services orprofessionals as appropriate.6. Establish local networks in partnership with other health and social professionals/agencies and national linkswith other generalists to develop protocols according to national and local guidelines for the safeand effective provision of a community nursing service.7. To work with partners in nursing and residential care to ensure optimum health outcomes for theirresidents.8. Critically analyse complex clinical data and information to inform diagnosis and, where appropriate, order investigationsand/or instigate therapeutic treatments to inform clinical decision making and improvehealth outcomes.
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