Complex Case Manager | East Lancashire Hospitals NHS Trust

Thepostholderwillbe thelinkbetweenprimarycare and keycoreproviderserviceswithinthelocality.YouwillbeworkingwithGeneralPractitioners,Practicestaff,CommunityservicesfromELHT,AdvancedNursePractitioner(s)(whereinpost),specialistservicesandpartnerprofessionals and agenciesfromwithinandbeyondtheINT to build high impact partnerships and drive transformation.

Youwillbedevelopingandpromoteacasemanagementapproachtocareandpromotingthebenefitsofco-ordinated,holisticcareforpatientsandfacilitatingthisprocessthroughthefacilitation,organisationandplanningof multi-disciplinaryteammeetings.Youwillneedto beappropriately trainedtounderstandholisticcareplanninganddeliverytoadviseINTmembersandcolleaguestodeliveraquality patientcentredservice.

The post holder provides a case management approach for patient with complex need in the community, within the Integrated Neighbourhood team. The post holder will work in the community assessing patients in the own environments, to provide the best possible patient outcomes. They will ensure collaborative working across divisions, with General Practitioners, partner professionals and agencies to secure care closer to home and positive outcomes for patients and their families.

The post holder will provide the leadership, direction, and line management necessary for effective and efficient service delivery and will support the Manger in the delivery of strategic and organisational initiatives and priorities, and reducing avoidable bed days/admissions, whilst maintaining high standards of clinical practice and professional conduct.

Car driver with access to a vehicle is essential

Please refer to job description for full details.

Established in 2003, East Lancashire Hospitals NHS Trust (ELHT) is a large integrated health care organisation providing high quality acute and community healthcare for the people of East Lancashire and Blackburn with Darwen.

The organisation puts safety and quality at the heart of everything we do, invests in and develops its workforce, works with key stakeholders to develop effective partnerships and encourages innovation and pathway reform to deliver best practice.

We employ over 8,000 staff, many of whom are internationally renowned and have won awards for their work and achievements.

The District Nursing Service provides a supportive environment and provides staff with many professional development opportunities
1. WorkwithinthemodeloftheINT,providingleadershipandsupportonthemattersrelatingtoadmission avoidanceandthetransferofcare.

1. Workcloselywithallservicesintegratingworkingpracticestostreamline processes,shareknowledge;andbenefit patientexperience,outcomesandflow.

1. Contributetothedevelopmentandprovisionofaresponsiveandproactiveneighbourhoodlocality basedapproach tothe preventionof avoidablehospitaladmissionsthroughthesupportandmentoringoftheCCMsandINTtoidentifyandmobiliseinterventionstoreduceriskandmaintainpatientsintheirownhomeenvironmentwherethisispossible.

1. ActasaresourceandfirstpointofcontactfortheComplex case Managers,toimprovecommunicationandconsistencyofcareforpatientsreceivinganumberofdifferentservicesandorrequiringadditionalsupporttominimiseriskofadmissionasidentifiedby riskprofiling,casefindingandlocalintelligence.

1. Ensurethecoordination,planninganddeliveryofregularmultidisciplinaryteammeetingshappens.

1. Chaircomplexmultidisciplinarymeetings,ensuringalldocumentationisrecordedregardingoutcomes,facilitatetheprocessofagreeingacasemanagerandcasemanagementapproach.

1. Supportcasemanagersinsettingupofmeetingsandliaisingwithappropriateservicesandthepatientandcarers where relevant.
2.

Toutiliseclinicalexpertisetofacilitatecareclosertohomeandpromotingaholistic,multiagencyresponsetocasemanagementtomeetthepatientsneeds.

1. Engageproactivelywithkeystakeholders(includingforexampleGeneralPractitioners,AdvancedPractitioners,theIntegratedNeighbourhoodTeams,specialistservices,SocialServices,independent/privatesectorproviders,andICAT/IHSSfromwithinandbeyondtheorganisationtoidentifypatientswhorequiresupportiveinterventionandcasemanagementtopreventavoidablehospitaladmissionandenablethoseindividualstoremainintheirownhomeenvironment.

1. Tofollowtheprogressofthosepatientsidentifiedoncasemanagementregistersfromthelocalitieswhoareadmittedtoacutecareandsupportanearlytransferhomeoncethepatient'sconditionhasstabilised,liaisingwithcasemanagersandmembersoftheintegratedteamandkeypartnerstoreducetherisksassociatedwithtransferofcare,

1. Toassess,receiveandreviewdataregardingpatientswhoregularlyattend/areadmittedtoacutecare,liaisingwithpatients;andrelatives/carersasappropriate;theintegratedneighbourhoodteamandkeystakeholderstodevelopaholisticcasemanagementapproachtosupportindividualstoremainindependentandpreventavoidablereadmission.

1. Tobeinvolvedwithandsupportthedevelopmentandongoingmaintenanceofdatamanagementsystems.

1. Contributetothedevelopmentandimplementationofsystemsandprocessesthatensuretheneedsofdisadvantagedgroupsareidentifiedandprogressedforexamplethehomelessandtravelling families.

1. Contributeand/orleadtrainingand/ordevelopmentactivitieswithinandbeyondtheDivisiontoraiseawarenessofcommunityprovision,capacityandcapability.

1. Activelypromoteafocusonself-care/managementtoreducerelianceonservicesandincreaselevelsofindependencewithinthepatientpopulation.

1. Workincollaborationwiththeintegratedneighbourhoodteamtoprovideinformation,preparepatientsandtheirfamilies/carersforchangesinthepatients'conditionandactivelyencourageandsupportdecisionmakingandchoiceforendoflifecareincludingtheuseof fasttrackandCHCprocesses.

1. Prioritiseandmanageownworkloadtoensureresponsivecare/interventionsbystaffwiththelevelofskillandcompetencetomeetpatientneedandprovideadviceandsupporttoteammembersregardingthecare/managementplan.

1. Responsibilityfor theworkloadoftheComplex Case ManagerSupport to ensurethesmoothrunningof theMDTmeetingsoccursandmeetsplannedobjectives.

1. Ensureownleadershipstylefacilitateseffectivecommunication,collaborationandmotivationofstaffandpartnerstopromoteanintegratedandholisticapproachtothemanagementoffuturecareforpatientsandcarers.