Job Summary
The MDT Nurse play 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 across health and care services.
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.
The MDT Nurse role is intended to become an integral part of the PCNs multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN.
Main duties of the job
– 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.
Job responsibilities
– Using clinical and nursing expertise determine that the patient is clinically optimised and that any acute episodes have resolved
– Identify and request appropriate assessment information as soon as the referral is received.
– Provide quality and clinical assurance for the assessment material, ensuring that it is appropriate and complete. If not, use sound clinical judgement to prioritise missing information required and refer to relevant professional in a timely manner.
– Ensure all additional information provided by an individual or their representatives is shared with the MDT in a timely manner.
– Identify appropriate individuals and secure their involvement as member of the MDT assessing eligibility
– Ensure the MDT meeting is arranged, coordinated, and communicated, with all necessary information available in a timely manner.
– Help MDT members to identify any significant gaps in information post assessment, and if so, assist in arranging for the necessary additional assessment information to be secured as soon as possible.
– Ensure all records are comprehensive, complete, available.
– Act as an impartial resource to the MDT, the individual undergoing assessment and/or their representatives on any policy or procedure questions that arise.
– If required, contribute to final decision-making of MDT eligibility recommendations in a fair, inclusive, and impartial way, utilising clinical knowledge.
– Must have a driving license and access to a car for home visits
– Adhering to all clinical governance standards, ensuring safe, efficient, and effective care, compatible with professional and national clinical standards.
– Attend relevant MDT meetings as required.
– Ensure that all MDT clinical policies are fully adhered to.