Please see the attached Job Description for further information. To actively engage with a wide range of stakeholders including staff, service users, their carers and other statutory and voluntary sector agencies to ensure people are fully briefed, know and understand commissioning and care management processes in relation to Continuing Healthcare, Funded Nursing Care, health and social care funded packages of care and section 117 aftercare. Impart complex and sensitive information to : Service user and families/carers re assessment, care planning, treatment and review Multi-disciplinary teams to ensure the provision of consistent well-coordinated care Primary care teams regarding client care External agencies also involved in the provision of care e.g.: voluntary and private sector, police, social services, housing, employment etc. Safeguarding, DOLS teams, Clinical Commissioning Groups and Devon County Council regarding concerns arising from commissioned packages of care. Liaise with a wide range of other professionals and agencies. To Liaise with Care Brokerage as appropriate. Contribute to the safe and effective day to day operations of the service including the handling of clinical enquires. Provide and receive information some of which may be contentious, sensitive and complex to and from individuals and their families/carers, where there may be barriers to understanding. Provide high standard of written and verbal communication that is clear and in line with professional documentation standards Participate in and chair clinical meetings, this will include multi-disciplinary meetings to agree DSTs and Section 117 reviews. Demonstrate the ability to communicate in a way that is effective, empathic and reassuring whilst employing negotiating techniques to gain co-operation from highly complex individuals. Communicate information in a way that makes it relevant and understandable for service users Analytical and Judgement skills Use clinical judgement to support the procurement and commissioning of packages of care for adults with a learning disability and complex health needs to ensure people are maintained within their local communities, avoid inappropriate admission to hospital and facilitate timely discharge from inpatient settings. Use clinical judgement to consider complex facts or situations, requiring analysis, interpretation and comparison of a range of options when determining the type of care package required for someone with complex health needs. Give written / oral evidence to support rationale to assist verification and funding panels in determining the eligibility for NHS Continuing healthcare Planning and Organisational Skills Organise and facilitate complex multi-disciplinary team meetings, these will include: DST review meetings and Section 117 aftercare meetings. Lead on the process for contentious decision making when other parties do not agree with outcomes with regard to eligibility for CHC or FNC funding. This may involve the wider MDT, service users, relatives, carers and advocates including legal representatives Plan and organise individuals packages of care and ensure that reviews are held within the required time frames, for example CHC, FNC and Section 117 annual reviews. Ensure care/support package meets the individuals assessed needs and agreed outcomes and is appropriate to achieve the identified intended outcomes in the care plan Responsible for managing their own workload to ensure the needs to the individuals who use our services are met taking the wider needs of the team into consideration. Ensure that interventions are planned in an integrated and co-ordinated manner particularly where dependent on other external agencies. Plan own workload and the workload of junior colleagues to ensure that care is provided in the most high quality and cost efficient manner, prioritise and make adjustments as appropriate. Responsibility for Individuals eligible for health funded care To be responsible for comprehensive high quality assessments to determine eligibility for Continuing Healthcare Funding in accordance with national framework. This will also include Funded Nursing Care and health and social care joint funding. To support the tendering of all agreed packages of care that fully meets the needs of individuals with complex health needs. To monitor procurement of cost effective services Responsible for reviewing a persons eligibility for Continuing Healthcare Funding and determining on going eligibility for CHC / FNC ensuring that the national framework is applied and adheres to all local policies and procedures. To monitor and review quality of care and support arrangements to ensure person is being safely supported in an environment which continues to meet their needs. To support discharge planning from Hospital and commissioning of future package of care and support. Responsible for Case Management of clients on Section 117 Aftercare, where required, as determined by DPT / DCC local policy. To be responsible for reviewing complex packages of care in partnership with clients, carers and multi-professional agencies and representatives. To lead on brokerage and procurement of alternative care and support for clients whose placements have broken down. To ensure funding and brokerage are completed within a timely manner to prevent unnecessary hospital admission. To support safeguarding investigations by reviewing quality and provision of health funded packages of care where required. To support transition of young people who are eligible for health funded packages of care when entering adulthood Responsibility for Policy and Service Development Implementation Be conversant with the vulnerable adult and child protection procedures and policies of the organisation To keep up to date with nursing practice and research, along with guidance from Nursing and Midwifery Council. To be responsible for own professional development and to keep up to date with current issues in the professional field Responsibility for Human Resources e.g. Supervision, training, HR advice and Management The post holder will deputise for the CHC lead nurse as necessary in his / her absence To supervise and support work of Band 5 staff in planning, prioritising and organising workload according to the needs of the service. To supervise Band 5 staff including yearly appraisal and professional development planning. There is a requirement to support learners on a regular basis which includes the achievement and updating of profession specific training to the required standard to fulfil this role. To act as a role model for other staff and students demonstrating high standards of practice and professional conduct To deliver appropriate training and subsequent support to other staff related to Continuing NHS Care To participate and facilitate clinical supervision To work within the standards set out by HCPC and N.M.C Code of Professional Practice To participate in and gather information for safeguarding vulnerable adult processes as required. Any Other Specific Tasks Required Practice in a way that actively minimises dependency and promotes recovery. Communicate information in a way that makes it relevant and understandable for service users and carers, working to the principles of the functions policy implementation guidelines and practice in line with the standards and values set out in them. Ensure a duty of care to service users who are entitled to receive safe and competent care. The service users wishes, feelings, values and beliefs should be taken into consideration as well as the views of the people close to them. Take personal accountability for your own practice. This means that you are answerable for your actions and omissions, regardless of advice or directions from another professional Ensure that you remain professionally competent by participating in your own and others clinical supervision. The ability to access all areas of Devon in a timely manner is essential. Some out of area work may be required from time to time The post-holder must be computer literate in order to type his/her own documentation and reports - it is important that these are accurate
