MDT Nurse

The MDT Nurse plays an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide co-ordination and navigation of care and support. Work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to people and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.,

• Work with people, their families and carers, to improve their understanding of their condition.
Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. Help people to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care. Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health. Provide co-ordination and navigation for people and their carers across health and care services. Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals Support the co-ordination and delivery of multidisciplinary teams with the PCN. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations.

MDT Nurses are caring, dedicated, reliable, person-focused and enjoy working with a wide range of people. Have good written and verbal communication skills and strong organisational and time management skills. Be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support.

Primary care networks (PCNs) form a key building block of the NHS long-term plan. Bringing general practices together to work at scale has been a policy priority for some years for a range of reasons, including improving the ability of practices to recruit and retain staff; to manage financial and estates pressures; to provide a wider range of services to patients and to more easily integrate with the wider health and care system. While GP practices have been finding different ways of working together over many years for example in super-partnerships, federations, clusters and networks the NHS long-term plan and the new five-year framework for the GP contract, published in January 2019, put a more formal structure around this way of working, but without creating new statutory bodies. Since 1 July 2019, all except a handful of GP practices in England have come together in around 1,300 geographical networks covering populations of approximately 3050,000 patients. This size is consistent with the size of primary care homes, which exist in many places in the country, but much smaller than most GP federations. Around 50 networks, usually in very rural areas, will cover a population of less than 30,000, but most are bigger than 50,000. If you would like the opportunity to make a difference in our community, come and join Sutton PCN