Community Sister - Hospital@Home

The post holder will be the Case Manager for a caseload of patients requiring complex case management and intervention as part of Wye Valley NHS Trusts Hospital at Home model in order to provide admission avoidance and/or early supported discharge from hospital.

As case manager, the post holder will have responsibility for proactively monitoring and managing patients on the caseload; as well as co-ordinating care and navigating the patient through pathways across the primary and secondary care interface.

Post holders will be expected to work late and early shifts, weekends and bank holidays according to the team rota.

Hours per week - Open to discussion

Main duties of the job

To work as part of an MDT to make clinical decisions (CDM) within the Community Integrated Response Hub (CIRH) to ensure the correct response to a new referral as part of admission avoidance.

To undertake a comprehensive baseline assessment for each identified patient

To implement a patient held personalised plan of care

co-ordinate the daily 'ward round' and highlight any significant changes or events which may indicate further action.

To ensure that the care given meets the standards and policies set by WVT

To ensure that there is effective communication with other departments and services (including Accident and Emergency, Ambulance and out of hours)

To perform and document examinations

To work with all members of the H@H team and other colleagues in acute care, and social services

To liaise with hospital colleagues in the event of a patient from H@H being admitted to hospital or attending A&E

To ensure that all discharges from the caseload are discussed and agreed

Being flexible to meet changing demands at short notice.

To communicate effectively with patients, relatives and colleagues

Managerial Responsibilities

To provide leadership to the H@H team

To be involved in recruiting and interviewing of staff as delegated

To use information, technology and ensure relevant and up to date information

To ensure that the service has adequate cover arrangements in place for annual leave and other absences

Wye Valley NHS Trust is a member of an NHS Foundation Group with South Warwickshire NHS FT , the George Eliot Hospital NHS Trust and Worcestershire Acute Hospitals NHS Trust.

Located on the border with Wales in the shadow of the Black Mountains, we provide acute and community services across Herefordshire and into parts of Powys and run Hereford County Hospital and the community hospitals in Bromyard, Leominster and Ross-on-Wye.

We are a progressive and forward looking trust with ambitious plans to improve quality and integrate patient pathways through close collaborative working with our partners to deliver the quality of care we'd want for our family and friends.

More than 3,500 people work for the Trust - they tell us it's a great place to work, blending the busyness of a DGH with the benefits of working in a beautiful rural and unspoilt county like Herefordshire.

We can offer a great work-life balance and have a fine tradition of working with staff to help them achieve their full potential.

Russell Hardy, Trust Chairman: "The strength of the Trust is its amazing staff; a great place to work, a great place to develop your career and a great place to reach your potential."

Our values -Care, Accountability, Respect and Excellence - are at the heart of all we do. We believe in providing the right care in the right place at the right time...all the time.