Continuing Care Case Manager

Job Purpose To be responsible for planning, managing and co-ordinating the care of people eligible for Continuing HealthCare and jointly funded care packages within a defined caseload. To delegate cases to Continuing Care Nurse Coordinators To make best use of Continuing Care Department resources and ensure that care packages are clinically appropriate. Work collaboratively across primary, secondary, social care and the voluntary sector to establish a whole systems approach to managing health and social care for the designated patient group. To ensure the Continuing Care Framework is followed and that care packages are clinically appropriate. To participate in on going professional development and clinical supervision for themselves and for other nurses within the team, including clinical supervision, via 1:1, objective setting, coaching and mentoring. Dimensions Managing an active caseload of people with mental health needs who receive funding for complex and Continuing Care packages. Networking and liaising with GP Practices and a variety of professionals across health and social care boundaries, statutory and voluntary organisations, patients and carers. Manage time effectively to meet the clinical activity of the identified case load. Clinical To work within the Continuing Care team ensuring that identified complex cases are managed appropriately. Using expert knowledge and autonomous decision making skills, manage a caseload of patients in the defined client group. Comprehensively assess, review and evaluate the needs of both patients and their carers for patients eligible for Continuing Healthcare. Work in partnership with patients, carers, GPs, case agencies, consultants, other health professionals and social care as appropriate to ensure complex care packages continue to meet ongoing clinical needs. To manage and delegate appropriately clinical work whilst overseeing clinical safety. To train, supervise and manage junior members of the team. This will include the use of formal appraisal documentation. To ensure that effective care provision is researched and auditable. To lead and participate in MultiDisciplinary Team meetings to ensure adequate outcomes of patient care packages. To deputise for Service Head in attending Joint Continuing Care Panel in providing specialist clinical advice for the eligibility for Continuing Healthcare. To provide specialist clinical advice to the Triage panel for all patients accessing the Continuing Care service. To be responsible for the promotion of best practice that ensures the health, safety and security of self, patients and colleagues in accordance with the policies, procedures and guidelines of the organisation. Practise in accordance with the procedures and guidelines for the Protection of Vulnerable Adults and Child Protection. Ensure that confidentially is protected at all times. Any other duties that may be reasonably required. Professional Actively engage in Clinical and managerial supervision. Maintain a personal development plan and professional portfolio. Participate in the PRD review process to identify training and development needs. Remain updated and ensure that clinical practice is evidence based. Leadership Establish clinical credibility to influence professional and organisational boundaries, acting as a role model for clinical excellence. Work collaboratively and in partnership with other practitioners to lead developments in professional practice ensuring that care practices, delivery and service development are evidence based. Take an active leading role in the development, implementation and evaluation of protocols and policies consistent with National Standards and research evidence, to support the development of community nursing. Initiate the interpretation of research findings, national and local policy, assessing the implications for the profession in collaboration with service managers. Encourage and support innovation, extensive networking, mentorship to professionals, exploration of new ways of working and sharing of expertise. Provide professional support and advice to colleagues and senior managers within the organisation. Contribute to the workforce and local delivery planning processes. Advise on professional standards and contribute to the Clinical Governance of the organisation. Demonstrate and promote advanced clinical skills to ensure patients and carers receive the best possible care and outcomes through clinically effective practice across the community nursing service. Share expertise with the inter-professional team to promote the development of nurses and the nursing profession. Actively participate in the development of teaching and communication strategies, addressing the learning needs of colleagues, patients and carers. Research and Development Continually evaluate and audit the quality and effectiveness of the practice of self and others, selecting and applying a wide range of valid and reliable approaches and methods that are appropriate to needs and context. Contribute to the wider development of practice by participating in research, audit, local and national presentations, networks and publications by attending national implementation workshops with the Department of Health and other national agencies. Assist in the development, implementation and evaluation of educational programmes for primary care workers to provide the necessary knowledge and skills for effective management of long term conditions. Participate in the future training of health students and staff and other professional groups. Communications & Relationships Internal Effectively communicate with patients and carers to ensure needs are identified and addressed and appropriate information and advice is provided. Facilitate effective communication between Primary, Secondary, Community, Social Care and voluntary settings to promote best possible outcomes. Provide high quality written reports and any other written documentation as required. External To participate in trust wide and multi professional meetings and deliver presentations at appropriate forums at local and, where necessary, regional level. To communicate highly complex information, with empathy and consideration to clients and carers. This may relate to patients diagnosis, prognosis and funding issues, therefore could be highly sensitive or distressing and associated with high degrees of emotion or conflict. This may include care of terminally ill patients, and imparting news of unexpected death to patients and relatives Media and Marketing To accept responsibility for media presentations both written and visual in both promoting CityCares image and dealing with media responses and through the direct marketing of CityCare services.