We have an exciting oppotunity for a Community Matron to join our dedicated Shrewsbury Community Nursing Team. Delivering holistic community-based care, through a proactive approach for people with long term conditions (LTC) or very complex health needs or very High Intensity Users (VHIUs) of hospital services to enhance the health and wellbeing of patients, prevent future avoidable hospital admissions and improve the patient experience. The post holder will provide a structured intervention for patients on their community nursing caseload and the wider community caseloads where appropriate, providing advanced assessment, interventions, care planning and facilitate multi-disciplinary working to enhance the persons health and wellbeing. The role will include the promotion of patient autonomy and activation for self-care / self-management, and forward plan for patients on their caseload to prevent future avoidable hospital admissions. The post holder will be a clinical expert for holistic nursing care in the locality and take the lead for developing and improving our community team's competency in delivering health promotion activities, complex care and nursing procedures towards improving the patient's health and wellbeing and quality of life.,

• To have an understanding of the vision of the Trust and be able to translate this into a local context for operational implementation within your multi-disciplinary team within your defined locality area.
• To assist the Locality Clinical Manager in promoting the vision and contributing to the establishment of an ethos of modern, customer orientated services and translate that into a culture of effective patient centred delivery in Locality setting.
• To identify, assess, diagnose, holistically treat and refer where necessary patients with Long Term Conditions (LTC), very complex care needs, or who are VHIU of hospital care.
• To proactively review, assess and communicate with those patients in order to anticipate the potential exacerbation of needs of patients with LTC and VHIUs in order to prevent any futureavoidable admissions into hospital services.
• To be the key worker responsible for co-ordinating the decisions about care and service provision for individual patient pathways across the Primary, Secondary care interface for their caseload and within the community nursing model of care.
• To influence and inform the development of a comprehensive care plan and where appropriate, advance care plan for people with LTC, very complex needs and VHIUs of hospital care. Community Neighbourhood Team.
  
  Shropshire Community Health NHS Trust provides community-based health services for adults and children in Shropshire, Telford and Wrekin, and some services in surrounding areas too. These range from district nursing, health visiting and running four community hospitals through to providing very specialist community care through talented and dedicated staff.
Patients, carers and the public play a vital role in helping us to develop and improve our services and we are constantly looking for ways to work with local communities, patients and the public to innovate and improve. Have a look at the Have Your Say section of our website to find out how you can feed back your experiences and help us to continually improve. Shropshire Community Health NHS Trust is an exciting place to work. It offers a wide range of employment opportunities for many people. Shropshire Community Health NHS Trust positively encourages applications from all areas of the community, regardless of age, gender, ethnicity, disability, sexual orientation or religious beliefs. We are committed to ensuring people who work for the community trust have a good working life - and a good work life/home life balance.