Cluster Frailty & Chronic Conditions Practitioner

This post is fixed term for 18-months, when it will be reviewed in line with the needs of the service.
The South East Wellbeing Centre, Cardiff (SEWeCC) service is a new multidisciplinary and multiagency collaborative initiative within C&VUHB aimed at coordinating the proactive and holistic management of patients whose needs may be better supported through the intervention of council, community and /or third sector services as a supplement to GP care and supported by health and social care professionals.
We are committed to ensuring that every patient receives the highest standard of care and support throughout their healthcare journey and as part of our commitment to excellence, we are seeking a dedicated and experienced Cluster Frailty & Chronic Conditions Practitioner to join our SEWeCC team.
This is a fixed term for 18 months due to funding, · Case manage an identified group of people with long term conditions/complex needs to support the prevention of unplanned hospital admissions, responding to patients who require urgent assessments and in collaboration with the patient, General Practitioner (GP) and Primary Care and community teams/social services, set up management plans with the aim of stabilising the individual's condition, enabling the patient to stay at home where possible.
· Inform, teach and mentor patients and their families with the aim of improving the patient's ability to understand and manage their long-term conditions.
· Work in partnership with the South East Wellbeing Centre, Cardiff across the cluster areas and collaborate with colleagues within the NHS and partner organisations to develop a consistent local multi-agency approach to managing long term conditions.
· Advanced care planning to improve communication and facilitate the co-ordination of patient care for those over 18 years of age at any stage of their health by involving the most appropriate professionals from health and social care, together with third sector providers. This will promote conversations between people, their families, carers and those looking after them, about their priorities, needs and preferences about their care now and in the future, enabling the relevant support to be provided enabling the appropriate delivery of care to meet these needs., Use advanced nursing skill and expert knowledge to assess the physical and psychosocial needs of a defined client group, instigating treatment based on best available evidence in order to stabilise the individual's condition.
To agree a personal management plan with the patient, ideally with inclusion of carers, relatives and other appropriate health care professionals. This will be based on a full assessment of medical, nursing and basic social care needs.
To use advanced nursing skills and expert knowledge to identify subtle changes in the patient's condition, analysing and interpreting complex health problems and associated scenarios.
To work with patients to identify problems from their perspective and develop holistic management plans.
To negotiate and agree with clients, carers, community nurse teams and other care professionals, individual roles and responsibilities with actions to be taken and outcomes to be achieved, referring on to other services or professionals as appropriate.
To work across professional and organisational boundaries, identifying areas for skill and knowledge development applying these to individual practice with the aim of providing continuity and high-quality patient centred care.
To enable patients and carers to manage their medications in conjunction with GP's, Pharmacists and other relevant clinical staff, including medication reviews as part of initial assessments and ongoing patient reviews.
To provide expert clinical care and health promotion.
Use expert knowledge and skill as a non-medical prescriber to independently prescribe within the individual practitioner's areas of prescribing competency.
Develop prescribing clinical management plans as appropriate in partnership with GP colleagues.
Advanced care planning to improve communication and facilitate the co-ordination of patient care for those over 18 years of age at any stage of their health by involving the most appropriate professionals from health and social care, together with third sector providers. This will promote conversations between people, their families, carers and those looking after them, about their priorities, needs and preferences about their care now and in the future, enabling the relevant support to be provided enabling the appropriate delivery of care to meet these needs.
Work to the NMC code of practice and maintain professional
MANAGING YOUR APPLICATION:
We are committed to promoting inclusion, where all staff have a sense of belonging. We welcome applications from everyone and recognise the need for our workforce to represent the diversity of the population we serve. We value our differences and fully advocate, cultivate and support an inclusive working environment where staff treat one another with dignity and respect and where diversity is celebrated. We aim to create a working environment where every individual can fulfil their potential no matter their disability, sex, gender identity, race, sexual orientation, age, religion or belief, pregnancy and maternity or marriage and civil partnership status. We are keen to break down barriers in the UHB, and encourage applications from under-represented groups.
Applicants are invited to apply in Welsh. Any application submitted in Welsh will not be treated less favourably than an application made in English.
The UHB reserves the right to close this vacancy after 24 hours if a large number of suitable applications are received. Therefore, we encourage early applications to ensure consideration for this post.
Please check your email account regularly. Successful applicants will receive all recruitment related correspondence via the email account registered on the application form.
To work in the UK, all candidates who are not UK or Republic of Ireland (RoI) nationals require sponsorship to obtain either a Health and Care visa or Skilled Worker visa, unless you have permission to work via another route. Non UK / RoI candidates wishing to apply should self-assess the likelihood of obtaining a Certificate of Sponsorship by visiting Work in the UK. If you are eligible for the Health and Care visa, application costs are lower and you do not need to pay the annual Immigration Health Surcharge.

Cardiff and Vale University Health Board is one of the largest Integrated Health Board in the UK, employing over 17,000 staff and providing over 100 specialist services. Serving a population of around 500,000 people living in Cardiff and the Vale of Glamorgan, we are focussed on the health
and care needs of our local population whilst also working with our partners to develop regional services. Together we are committed to improving health outcomes for everyone and to delivering excellent care and support.
Our mission is "Living Well, Caring Well, Working Together". We have recently refreshed our strategy, Shaping Our Future Wellbeing, which sets out the Health Board's Vision for improving the health and wellbeing of the populations we serve by 2035 through the delivery of our strategic
objectives; Putting People First, Providing Outstanding Quality, Delivering in the Right Places, and Acting for the Future. We have challenging times ahead, but we are confident that by tackling these challenges together, we can support people to live healthier lives and reduce the unfair differences in
the prevalence of illness and health outcomes we see in our communities today. We aspire to deliver outstanding care and treatment for people when they need it, where they need it; care that compares well with the best in the world, but to do so, we need to transform how we deliver services over the
next decade and beyond.
We are a values-driven organisation and out goals will only be realised if our values are at the heart of everything we do. Created by colleagues, patients and their families and carers, our values are:
+ We are kind and caring
+ We are respectful
+ We have trust and integrity
+ We take personal responsibility
As an organisation we strongly believe that it is vital our leaders exhibit the behaviours and values that we expect from all our staff.
We are a teaching Health Board with close links to the university sector, and together we are training the next generation of healthcare professionals, while working on research that will hopefully unlock the cures for today's illnesses
Please be advised that there is a temporary top up for Bands 1,2 and 3 to reflect the incorporation of the top up to the living wage of £12 per hour - £23,465 per annum. This temporary top up will be in place until the annual pay uplift for 2024/25 is confirmed, Cardiff and Vale University Health Board is one of the largest Integrated Health Boards in the UK, employing over 15,000 staff, providing over 100 specialist services. Working across 6 hospital sites, we have a diverse range of career opportunities to offer. Serving around 500,000 people living in Cardiff and the Vale of Glamorgan, we are focussed on the health and care needs of our local population whilst working with our partners to develop regional services.
Our mission is "Caring for People, Keeping People Well", and our vision is that every person's chance of leading a healthy life should be equal. As an organisation we are unashamedly ambitious for our population's health, rising to the challenges of today and tomorrow through our 10-year strategy, Shaping our Future Wellbeing. We are contributing to a healthier Wales with great emphasis placed on innovation and improvement, learning from around the world and leading the way in clinical research. Partnership working is strong at Cardiff and Vale, and we work closely with our staff and our community.
Cardiff, the thriving Welsh capital, is a fantastic city to live and work in with an abundance of sports, arts and cultural attractions. Situated to the west of Cardiff, the Vale of Glamorgan offers a combination of beautiful Welsh countryside and a dramatic natural coastline. Whether city life or rural living, Cardiff and the Vale offers the best of both worlds.