Community Matron Bury Rural INT

JOB PURPOSE: • To co-ordinate care provision through a case-management approach for a defined high risk patient group with complex long-term conditions (such as COPD, diabetes and CHD) with the aim of preventing unnecessary hospital admissions and facilitating timely discharge. • To provide the highest standard of clinical care by using advanced skills and expert knowledge to holistically assess needs and instigate and provide clinical treatments based on evidence-based practice. • To participate in the delivery of educational programmes to patients, carers and Health & Social Care workers that promote self care principles. • To develop and promote robust multidisciplinary working across the wider Health and social Care sectors to ensure integrated services and support networks for patients. • To monitor the quality of care provision and to identify and promote areas for service development. Job description Job responsibilities JOB PURPOSE: • To co-ordinate care provision through a case-management approach for a defined high risk patient group with complex long-term conditions (such as COPD, diabetes and CHD) with the aim of preventing unnecessary hospital admissions and facilitating timely discharge. • To provide the highest standard of clinical care by using advanced skills and expert knowledge to holistically assess needs and instigate and provide clinical treatments based on evidence-based practice. • To participate in the delivery of educational programmes to patients, carers and Health & Social Care workers that promote self care principles. • To develop and promote robust multidisciplinary working across the wider Health and social Care sectors to ensure integrated services and support networks for patients. • To monitor the quality of care provision and to identify and promote areas for service development.