Community Oxygen Specialist Nurse/Physiotherapist

The COPD Community Matron / case manager will be expected to: • To be responsible and accountable for providing expert care to Oxygen patients who are registered with a Greenwich GP • Utilisation of advanced clinical skills and expert knowledge to plan, implement, monitor and review individualised patient-directed programmes of care to patients with home oxygen therapy including health promotion interventions. • To undertake goal centred interventions that are evidence-based, evaluating the effectiveness of these at regular intervals with a view to improving care continuously. • Develop risk management plans that will enable individuals to remain safely within their homes • Use expert knowledge and skills as a non medical prescriber to manage patient medication within own areas of competency, developing clinical management plans in partnership with GP colleagues where necessary. • Anticipate individual care needs and develop appropriate care plans, involving carers and relatives • To provide individuals and their carers with the necessary education that will enable them to plan for unavoidable disease progression and self manage as far as possible. • To work collaboratively with members of the multi professional team to ensure that the patients needs are met, making appropriate referrals are made where necessary. • Develop practices which promote patient choice and well-being • To be responsible for ordering stock and other resources when asked • Ensure that the needs of individuals who are vulnerable are highlighted and addressed in a timely manner • To be a competent clinical leader demonstrating a willingness to work as an integral part of a multi professional team • Be a highly skilled communicator, written and verbal, with a capability for communicating within a variety of professional groups, challenging attitudes where necessary • To manage a caseload of patients with home oxygen therapy (Specialist community matron/case manager) • To practice at an advanced level demonstrating an in-depth knowledge of all aspects of the management of COPD that is evidence-based • To undertake advanced physical and social assessments and examinations, and initiate appropriate diagnostic activity and treatment • To work with other community matrons/case managers to ensure a consistency of approach to patient care and to support clinical supervision arrangements within the Trust • To work collaboratively with other specialist and multidisciplinary teams, such as GPs, District Nurses, Consultants • To support COPD self management programmes such as GRACE and pulmonary rehabilitation • To contribute towards reducing frequent admissions and bed days of patients with COPD • To help improve the diagnostic rate of COPD in primary care supporting the delivery of an ARTP accredited quality assured spirometry clinic. • To work alongside the clinical lead in the new/confirmed diagnosis of COPD in producing treatment plans including self-management and education at consultant lead MDT sessions • To participate in the delivery of education sessions on the Greenwich Respiratory Advice and self-Care Education (GRACE) programme in a community • To be confident in the delivery of educational topics including: pathophysiology of COPD, COPD medications, managing exacerbations, breathlessness, productive cough, anxiety and low mood and the importance of exercise and a balanced diet • To participate in the delivery of pulmonary rehabilitation with the support of the pulmonary rehabilitation lead • To participate in disease specific audit and data collection • To act in accordance with the clinical governance framework within the Trust • To share knowledge and skills with patients and families as a key therapeutic intervention and to enable self care and autonomy • To identify the educational requirements of primary and social care colleagues in relation to the management of home oxygen therapy and lead on meeting these needs • To participate in clinical supervision, appraisal and personal development programme • Ensure own professional development and clinical skills through attending courses, workshops and conferences and applying the knowledge gained in clinical practice • To interface with primary and secondary care teams to enable the implementation of managed care pathways in line with local and national guidance • To advise on and develop new initiatives and ways of working informed by local and national policy • To be involved in the development of guidelines, policies and protocols within the Trust • To promote effective collaborative working relationships with health and social care colleagues and those within support networks and the voluntary sector • To act as a change agent and innovator, planning, instigating and evaluating changes • To proactively demonstrate the positive impact of case management on the reduction of avoidable admissions and lengths of hospital stay • Contribute to the service development within the Trust in line with national strategies particularly those referencing respiratory care. • To maintain accurate and legible and timely records • To act as leader, mentor and preceptor to staff within the Trust Job description Job responsibilities The COPD Community Matron / case manager will be expected to: • To be responsible and accountable for providing expert care to Oxygen patients who are registered with a Greenwich GP • Utilisation of advanced clinical skills and expert knowledge to plan, implement, monitor and review individualised patient-directed programmes of care to patients with home oxygen therapy including health promotion interventions. • To undertake goal centred interventions that are evidence-based, evaluating the effectiveness of these at regular intervals with a view to improving care continuously. • Develop risk management plans that will enable individuals to remain safely within their homes • Use expert knowledge and skills as a non medical prescriber to manage patient medication within own areas of competency, developing clinical management plans in partnership with GP colleagues where necessary. • Anticipate individual care needs and develop appropriate care plans, involving carers and relatives • To provide individuals and their carers with the necessary education that will enable them to plan for unavoidable disease progression and self manage as far as possible. • To work collaboratively with members of the multi professional team to ensure that the patients needs are met, making appropriate referrals are made where necessary. • Develop practices which promote patient choice and well-being • To be responsible for ordering stock and other resources when asked • Ensure that the needs of individuals who are vulnerable are highlighted and addressed in a timely manner • To be a competent clinical leader demonstrating a willingness to work as an integral part of a multi professional team • Be a highly skilled communicator, written and verbal, with a capability for communicating within a variety of professional groups, challenging attitudes where necessary • To manage a caseload of patients with home oxygen therapy (Specialist community matron/case manager) • To practice at an advanced level demonstrating an in-depth knowledge of all aspects of the management of COPD that is evidence-based • To undertake advanced physical and social assessments and examinations, and initiate appropriate diagnostic activity and treatment • To work with other community matrons/case managers to ensure a consistency of approach to patient care and to support clinical supervision arrangements within the Trust • To work collaboratively with other specialist and multidisciplinary teams, such as GPs, District Nurses, Consultants • To support COPD self management programmes such as GRACE and pulmonary rehabilitation • To contribute towards reducing frequent admissions and bed days of patients with COPD • To help improve the diagnostic rate of COPD in primary care supporting the delivery of an ARTP accredited quality assured spirometry clinic. • To work alongside the clinical lead in the new/confirmed diagnosis of COPD in producing treatment plans including self-management and education at consultant lead MDT sessions • To participate in the delivery of education sessions on the Greenwich Respiratory Advice and self-Care Education (GRACE) programme in a community • To be confident in the delivery of educational topics including: pathophysiology of COPD, COPD medications, managing exacerbations, breathlessness, productive cough, anxiety and low mood and the importance of exercise and a balanced diet • To participate in the delivery of pulmonary rehabilitation with the support of the pulmonary rehabilitation lead • To participate in disease specific audit and data collection • To act in accordance with the clinical governance framework within the Trust • To share knowledge and skills with patients and families as a key therapeutic intervention and to enable self care and autonomy • To identify the educational requirements of primary and social care colleagues in relation to the management of home oxygen therapy and lead on meeting these needs • To participate in clinical supervision, appraisal and personal development programme • Ensure own professional development and clinical skills through attending courses, workshops and conferences and applying the knowledge gained in clinical practice • To interface with primary and secondary care teams to enable the implementation of managed care pathways in line with local and national guidance • To advise on and develop new initiatives and ways of working informed by local and national policy • To be involved in the development of guidelines, policies and protocols within the Trust • To promote effective collaborative working relationships with health and social care colleagues and those within support networks and the voluntary sector • To act as a change agent and innovator, planning, instigating and evaluating changes • To proactively demonstrate the positive impact of case management on the reduction of avoidable admissions and lengths of hospital stay • Contribute to the service development within the Trust in line with national strategies particularly those referencing respiratory care. • To maintain accurate and legible and timely records • To act as leader, mentor and preceptor to staff within the Trust