Specialist Neighbourhood Nurse (SNN)

The development of Integrated Neighbourhood working is supportingProviders to work in a joined-up way. and Primary Care plays a key role in thesuccess of Integrated Neighbourhood working, supporting patients to self-managetheir condition or be assisted to manage their health needs closer to home, intheir local communities., The role of the Specialist Neighbourhood Nurse is to support both the practice staff and members of the Neighbourhood Team t identify and support people to reduce the risk of unplanned hospital admissions and to effectively support those individuals in the community. To pro-actively engage with people deemed to be at a high risk of hospital admission

• To pro-actively engage with the in-reach teams to reduce length of stay in hospitals
• To pro-actively engage with people living in care homes
• To pro-actively engage with housebound people
• To be the key contact for people at the practice
To liaise with the registered GP and other practice-based staff in addition to all other providers and services utilising, where appropriate, a multi-disciplinary approach. To implement and review individual care plans, a self-management plans and to agree trigger thresholds to contact Case Managers / GPs. Planned visits to Nursing and Residential homes to be undertaken every 3-6 months, providing training as required. To ensure all people in Nursing and Residential homes have care plans (including dementia where needed) and to provide a holistic review of all people in these homes with updates of their care plans. Provide enhanced support to Nursing and Residential home with a focus on strengthening relationships and improving access through information sharing, education and advice., General duties Health and Safety- It is theresponsibility of the individual to work in compliance with all current Healthand Safety legislation and the Practice Health and Safety Policy. To attend anytraining requirements, both statutory and mandatory, in line with the legalresponsibility to comply with the Health and Safety at Work Act. The roles contains the following responsibilities : To maintain registration with the NMC. To adhere to the NMC Code. To support training and development. To maintain personal professional competency and appropriatedevelopment. To carry out the duties and responsibilities of the post in accordancewith the Practice Policies including duty of candour and whistleblowing. Required to comply with all relevant national and local statutory andmandatory requirements including Health and Safety, Infection Control,Safeguarding, Information Governance, Research Governance and Equality andHuman Rights. To implement and review individual care plans, a self-management plansand to agree trigger thresholds to contact Case Managers / GPs. Plan visits to housebound people, undertake every 3-6 months, andarrange care plans where necessary Provide enhanced support to Nursing and Residential home with a focus onstrengthening relationships and improving access through information sharing,education and advice. Planned visits to Nursing and Residential homes to be undertaken every3-6 months, providing training as required. To ensure all people in Nursing and Residential homes have care plans(including dementia where needed) and to provide a holistic review of allpeople in these homes with updates of their care plans. To contact people where necessary to advise them of the role ofSpecialist Neighbourhood Nurse Visit people at home following the identification of urgent clinicalneed including those escalated by EMAS or a member of the Neighbourhood Team,undertake a personalised comprehensive assessment, in order to diagnose, treatand prescribe within the limitations of your registration and competence Visit people at home following an unplanned hospital admission and thosewith a history of repeat admissions, within 2 weeks. Contact those that have suffered a bereavement. Arrange dedicated appointments in practice, for those who wish to visit,with flexibility to expand up to 30 minutes, or as needed. Key Responsibilities Act as a point of contact between GP, Neighbourhood Team, people andtheir carers. Develop and maintain a detailed knowledge of local services to enablesupported signposting of people with identified need, sharing information withthe Neighbourhood Team. Liaise with GPs and practice teams to identify people who are elderly,frail or who have long term health needs and support. Liaise with primary, secondary and specialist care services as required. Work with the Neighbourhood Team to help identify people at risk of lossof independence or admission to hospital as a result of inadequate socialsupport. Provide these cohorts of people signposting to identified services inorder to maintain their independence and improve their health and well-being. Visit people in community, home or care home settings to assess anddiscuss their care needs involving carers as appropriate. Implement personal care plans for individual people, ensuringpreventative actions are detailed to support the appropriate use of services. Communicate the care plan to the GP and any other members of theNeighbourhood Team involved in the persons care and upload to the relevantrecords. Ensure that identified people receive the right level of help at theright time and help them to experience a joined-up service by liaising withrelevant members of the Neighbourhood Team. Work with patient, carers and the Neighbourhood Team to encourage thepatient to adopt effective self-management and self-help seeking approaches toreduce unnecessary hospital admissions. Liaise with other agencies to ensure timely and appropriate engagementas required. Support people to access community care assessments as well as carersassessments. Where a personal healthcare budget is allocated provide advice asrequired regarding the key choices the patient will need to make. Identify unpaid carers and direct them to access services as appropriateto provide them with support. Identify when urgent action or a step up in care is required andpromptly alert the relevant member of the Neighbourhood Team, highlighting anysafety concerns. Follow up on communications from out of hospital and in-patient servicesregarding changes in condition of people to support the practice to respondproactively to potentially unmet needs. Undertake visits or telephone contact to manage people on the SNNs caseload following any unplanned hospital admissions where appropriate. Participate in Practice multi-disciplinary meetings to discuss Practicepeople actively being managed by the Neighbourhood Team and any other peoplefrom the SNNs case load needing discussion. To attend Neighbourhood Team MDT meetings at the Practice plus any othermeetings where there is a need to discuss Practice patients. Undertake visits or arrange appointments at the Practice for people onthe SNNs case load or otherwise as directed by the Duty Doctor followingidentification of urgent and non-urgent clinical need to assess, diagnose,treat, prescribe and refer appropriately according to the patients healthneeds and acting within the SNNs clinical skill set. Maintain accurate and up to date records of patient contacts using GPrecord systems and other IM&T systems relevant to the role enteringnotes onto Systmone / EMIS using agreed read codes and VMDT To run regular patient searches using Systmone / EMIS in order to havean up-to-date record of progress of achievement of Key Performance Indicators. Work with South Lincolnshire ICB, Neighbourhood Teams and other agenciesto support and further develop this role. Support the Practice Manager in providing KPI reports for submission asrequested.


• IT skills
• Knowledge of Personalisation, and personalised care, that gives people control over their health & care ,based on their needs and what's important to them.
• It's intended to improve health & wellbeing by helping people make decisions about their care, and by making the most of the skills and potential of people, families and communities.
Experience Essential
• Experience of dealing with people with long term conditions
• Evidence of ability to work autonomously
• Evidence of working within a multidisciplinary team
Desirable
• Experience of working in Primary Care
• Experience of working in a GP practice
Qualifications Essential
• Registered Nurse Level One
• Post graduate study in health-related studies relevant to long term conditions or equivalent experience
• Evidence of continuing professional development
• Post registration teaching qualification or willingness to undertake
• Post registration qualification in non-medical prescribing or willingness to undertake as needs of service change
  
  Spalding PCN is made up of Munro Medical Centre & Beechfield Medical Centre.
The development of Integrated Neighbourhood working is supportingProviders to work in a joined-up way. and Primary Care plays a key role in thesuccess of Integrated Neighbourhood working, supporting patients to self-managetheir condition or be assisted to manage their health needs closer to home, intheir local communities. This approach enables more people with health andsocial care complexities to achieve a greater balance in all round health.