Specialist Nurse for Care Homes

The Complex Case Management in Care homes service utilises an MDT approach under the Enhanced Health in Care homes framework (EHCH). The postholder will act as a Senior Nurse and work closely with Primary care, community services, Care Home Managers and Social Care teams to support effective interventions for Care Home residents. The aim of the role is to reduce hospital admissions and maintain high standards of care in the community. The post holder will work across a range of organisations and services and provide clear coordination of the EHCH model for Greenwich. To ensure the coordination of agreed interventions are planned, managed and delivered effectively with support of the MDT. This will include direct working relationships with Care Home Staff, Geriatricians, LAS, GP's, other Primary Care professionals and Adult Social Care with the inclusion of other service providers when appropriate.

• Have a good understanding of working with complex health issues and particularly older adults living with frailty, residing in Care Homes
• Able to build good relationships with key stakeholders and the MDT and communicate effectively.
• Have experience of working with an MDT and be able to lead staff of different disciplines, working collaboratively with medical colleagues.
• Work closely with key stakeholders in South East London.
• Work as part of the Greenwich Home First and Virtual Ward programmes to develop care closer to home and support early hospital discharge., To support the on-going delivery of a robust and resilient Enhanced Health in Care Homes Model in Greenwich by conducting modified Comprehensive Geriatric Assessments and participating in weekly virtual Multi-Disciplinary Team (MDT) reviews of patients on the caseload.
• To support coordination of the MDTs with partners for an agreed cohort of individuals who are Care Home residents with multiple health needs or are high intensity users of A& E with multiple presentations.
• Working with the MDT including GPs, Care Home Staff and acute hospital including consultants and other key system partners in identification of frequent attenders and production of Advance Management Plans.
• Maintain regular contact for GPs, LAS and other service providers to flag up high impact users to prevent hospital admissions.
• Organising and chairing the virtual MDT meetings, in the absence of the service lead, ensuring attendance and engagement of key players.
• Profiling and highlighting agreed MDT outcomes, ensuring action is taken for the cohort of individuals identified including robust plans of care, anticipatory care planning is in place.
• To ensure collaborative working is undertaken across Greenwich with regards to frequent attenders/ high impact users/multiple emergency spells.
• Complete a data base of this cohort of patients. Utilising this to implement a more robust model within Greenwich for the overall identification and management for this cohort of patients.
• Actively contribute to capacity planning and review processes and link to the Frailty PCN Model.
• Take a lead role in the use of Universal care plan completion and maintenance for care home patients and support the MDT to ensure this is utilised effectively.
  
  3 or more years as a Band 6 Nurse in a relevant specialty, Experience of working within a multidisciplinary team
• Relevant post registration learning in older adults/frailty
• Experience of working with people living with Dementia
  
  Oxleas offers a wide range of NHS healthcare services to people in community and secure environment settings. Our services include community health care such as district nursing and speech and language therapy, care for people with learning disabilities and mental health care such as psychiatry, nursing and therapies. Our multidisciplinary teams look after people of all ages and we work in close partnership with other parts of the NHS, local councils and the voluntary sector and through our new provider collaboratives. Our 4,300 members of staff work in many different settings including hospitals, clinics, prisons, secure hospitals, children's centres, schools and people's homes.We have over 125 sites in a variety of locations in the South of England. In London we operate within the Boroughs of Bexley, Bromley Greenwich and into Kent. We manage hospital sites including Queen Mary's Hospital, Sidcup and Memorial Hospital, Woolwich, as well as the Bracton Centre, our
medium secure unit for people with mental health needs. We are the largest NHS provider of prison health services providing healthcare to prisons within Devon, Dorset, Bristol, Wiltshire and Gloucestershire, Kent and South London. We are proud of the care we provide and our people. Our purpose is to improve lives by providing the best possible care to our patients and their families. This is strengthened by our new values:
• We're Kind
• We're Fair
• We Listen
• We Care