Community Matron

Duties and Responsibilities 1. Maximise independence by supporting people with long term conditions and highly complex needs to remain in their own homes as appropriate, by utilising and commissioning available resources. 2. Undertake clinical assessment and provide treatment for patients within the defined group. 3. Link with existing services to facilitate successful discharges and to prevent re-admission to hospital. 4. Develop Partnerships and joint working within the local health and social care economy. 5. Work collaboratively across organisation boundaries to support the effective and co-ordinated provision of social care and health care services. Clinical Requirements: 6. Conduct a comprehensive health and social care assessment, utilising any current information in order to develop an individualised plan of care for patients within a defined group. This will include: - Review of health assessment including medical history - Physical examination - Assessment and review of medication - Making referrals for diagnostic tests - Functional /cognitive assessment - Assessment of social care needs. 7. Develop, monitor, and manage the plan of care in collaboration with the primary health and social care team and others through: - Application of clinical knowledge about long term conditions - Analysis of symptoms and data - Identification of risk factors associated with exacerbation of patients condition - Recognition of early signs and symptoms of acute illness. - Involving patients and carers in the development of the care plan and ensuring that their views and abilities are reflected. - Documentation of progress and continuous reassessment - Referral and investigation. Set up and actively participates in case review to evaluate the outcomes of care plans including social care needs. 8. Co-ordinate care and treatment to avoid fragmentation, duplication, and delay in the least intensive setting appropriate to the patients needs by: - Prioritisation and co-ordination of multiple health and social care needs - Referrals to specialist services - Ensuring effective communication and sharing of appropriate information amongst professionals to avoid conflicting treatments. - Integration across health and social care (inc. voluntary sector and housing) - Identifying deficiencies in service provision and addressing these as appropriate (ie through commissioning services for individuals) - Understanding and working through entitlements to social care and necessary financial assessments. 9. Be aware of and adhere to, the Professional bodies Standards for administration of Medicines Act 1992, and the Misuse of Drugs Act 1971. Further details of the Job Description please see attached document. Job description Job responsibilities Duties and Responsibilities 1. Maximise independence by supporting people with long term conditions and highly complex needs to remain in their own homes as appropriate, by utilising and commissioning available resources. 2. Undertake clinical assessment and provide treatment for patients within the defined group. 3. Link with existing services to facilitate successful discharges and to prevent re-admission to hospital. 4. Develop Partnerships and joint working within the local health and social care economy. 5. Work collaboratively across organisation boundaries to support the effective and co-ordinated provision of social care and health care services. Clinical Requirements: 6. Conduct a comprehensive health and social care assessment, utilising any current information in order to develop an individualised plan of care for patients within a defined group. This will include: - Review of health assessment including medical history - Physical examination - Assessment and review of medication - Making referrals for diagnostic tests - Functional /cognitive assessment - Assessment of social care needs. 7. Develop, monitor, and manage the plan of care in collaboration with the primary health and social care team and others through: - Application of clinical knowledge about long term conditions - Analysis of symptoms and data - Identification of risk factors associated with exacerbation of patients condition - Recognition of early signs and symptoms of acute illness. - Involving patients and carers in the development of the care plan and ensuring that their views and abilities are reflected. - Documentation of progress and continuous reassessment - Referral and investigation. Set up and actively participates in case review to evaluate the outcomes of care plans including social care needs. 8. Co-ordinate care and treatment to avoid fragmentation, duplication, and delay in the least intensive setting appropriate to the patients needs by: - Prioritisation and co-ordination of multiple health and social care needs - Referrals to specialist services - Ensuring effective communication and sharing of appropriate information amongst professionals to avoid conflicting treatments. - Integration across health and social care (inc. voluntary sector and housing) - Identifying deficiencies in service provision and addressing these as appropriate (ie through commissioning services for individuals) - Understanding and working through entitlements to social care and necessary financial assessments. 9. Be aware of and adhere to, the Professional bodies Standards for administration of Medicines Act 1992, and the Misuse of Drugs Act 1971. Further details of the Job Description please see attached document.