This is an exciting and innovative role which will involve working alongside community GPs, paramedics, pharmacists, district nurses, adult social care, voluntary organisations and community matrons to support the delivery of proactive healthcare and support to people living with frailty, multiple long-term conditions and/or complex needs to help them stay independent and healthy for as long as possible at home.,

• Take clinical responsibility for the patient and work collaboratively with all professionals, carers and relatives to gain a deep understanding of all aspects of the patient's physical, emotional and social situation.
• Conduct physical examination and detailed history taking, diagnosis and treatment planning.
• Develop a personalised care plan for the patient based on the full assessment of medical, nursing and care needs. This includes preventative measures and anticipation of future health needs.
• Plan, implement, monitor and review therapeutic interventions with individuals who have a long term condition and their carers.Be competent or become competent in using the Comprehensive Geriatric assessment when assessing patients ensuring all patients over the age of 65 are Rockwood scored.
• Use relevant nursing assessment tools to ensure best practice is achieved
• Use EMIS CM template to complete assessments.
• Be competent or become competent in advanced care planning on an individual basis with the patient and be competent in the completion of a RESPECT form if relevant.
• Enable individuals with long term conditions to manage their medicines and their conditions independently
• Co-ordinate and review the delivery of care plans to meet the needs of individuals with long term conditions or complex needs
  
  Surrey Downs Health and Care deliver care closer to people's own communities through our Primary Care Networks, Community Hospitals, Specialist Services and our innovative partnership of local NHS organisations.
Surrey Downs Health and Care has a track record of providing person centered care that goes beyond organisational boundaries to do what is best for the individual. This partnership includes:
• The three GP federations GP Health Partners, Dorking Health representing practices that operate in the Surrey Downs area
• CSH Surrey
• Epsom and St Helier's University Hospitals NHS Trust
• Surrey Council County
Historically, there have been boundary lines between the organisations that provide care to people in their homes, in GP surgeries and in hospitals, but we have always been united in our mission to provide great care to the people who need us. It's on those grounds that the Surrey Downs Health and Care was formed - we want local people to receive the care that they need in the right environment. By bringing together our expertise, we can improve patient care and enable local people to access the right support, care and treatment more easily than ever before. In bringing this partnership together, we are working to the same set of values that will translate into better care for our residents.