Community High Intensity Nurse Case Manager - Countywide

Job description

Job summary

An exciting opportunity has arisen for a motivated and experienced Qualified District Nurse to join our Community High Intensity User Service as a Nurse Case Manager.

This innovative role focuses on supporting individuals who frequently access urgent and emergency healthcare services and often have complex physical health, frailty, mental health or social care needs. Through proactive case management, comprehensive assessment and coordinated multidisciplinary working, you will help patients achieve better health outcomes while reducing avoidable Emergency Department attendances and hospital admissions.

Working across community, primary care, acute, mental health, social care and voluntary sector services, you will develop personalised care plans that address the underlying causes of repeated healthcare use. You will build strong therapeutic relationships with patients, families and carers, supporting individuals to access the right care, at the right time, in the right place.

This is an excellent opportunity to contribute to an innovative service that improves patient experience, promotes independence and supports more effective use of healthcare resources across the Buckinghamshire healthcare system.

Main duties of the job

The postholder will manage a designated caseload of high intensity users, undertaking comprehensive holistic assessments and developing personalised care plans to address complex health and social care needs. They will act as the lead coordinator for patients requiring multi-agency input, ensuring effective communication and collaboration between primary care, community services, acute trusts, mental health services, ambulance services, social care and voluntary sector organisations.

The Community High Intensity User Nurse Case Manager will proactively monitor patients at risk of deterioration, provide timely interventions following emergency department attendances, hospital admissions or discharge, and lead multidisciplinary reviews to support coordinated care delivery. They will work closely with patients and carers to promote self-management, facilitate advance care planning and develop crisis and escalation plans that reduce avoidable admissions and emergency service use.

The postholder will also contribute to service development, quality improvement and outcome measurement, providing specialist advice, education and support to colleagues across the wider healthcare system. Through strong clinical leadership and partnership working, they will help deliver improved patient experience, enhanced health outcomes and more effective use of healthcare resources.

About us

Listen to why colleagues think we are a great place to work! - BHT - A great place to work (buckshealthcare.nhs.uk)

What does Buckinghamshire Healthcare NHS Trust offer you?

• As part of our BHT family, you'll benefit from learning and development opportunities to support your career progression.
• We offer flexible and agile workingopportunities,alongside your NHS benefits ofgenerous annual leave entitlement, pension andaccess toNHS discount schemes.
• We provide a range of health and wellbeing services to promote a healthy, happy workforce.

Why work for us?

• We're committed to promoting inclusion and making sure all colleagues feel they belong. We encourage new colleagues from a diverse range of backgrounds to apply.
• As an employer, we aim to create a workplace where differences are valued and colleagues treat one another with dignity and respect.
• Greater diversity withinourBHT familyimprovespositive outcomes for the people and communities we serve.
• A keen supporter of the Armed Forces Community who know the value of employing a service leaver/veteran and their families.

What do we stand for?

• Our vision is to provide outstanding care, support healthy communities and be a great place to work.
• Our mission is to provide personal and compassionate care every time.
• Our care values are collaborate, aspire, respect and enable.

Job description

Job responsibilities

For a comprehensive list of responsibilities and duties, please kindly refer to the Job Description and Person Specification by downloading the JD and PS attachment in the advert.

If you are an internal applicant there is the option for secondment, all applicants must have the endorsement/support of their line manager prior to application.

If you have a disability that makes submitting this online application difficult and would like assistance, please contact us on [email protected] quoting the vacancy reference number.

Job description
Job responsibilities

For a comprehensive list of responsibilities and duties, please kindly refer to the Job Description and Person Specification by downloading the JD and PS attachment in the advert.

If you are an internal applicant there is the option for secondment, all applicants must have the endorsement/support of their line manager prior to application.

If you have a disability that makes submitting this online application difficult and would like assistance, please contact us on [email protected] quoting the vacancy reference number.

Person Specification

2.EDUCATION, QUALIFICATIONS & TRAINING

Essential

• Registered Adult Nurse with current NMC registration.
• Community Specialist Practitioner Qualification.
• Evidence of continuing professional development.
• Full UK driving licence and access to a vehicle.
• Long term conditions module
• Advanced Clinical Assessment Qualification.
• Teaching qualification or Practice Assessor or Mentorship Qualification

Desirable

• Non-Medical Prescribing Qualification.
• Palliative care module
• Master's Degree or equivalent experience

Experience

Essential

• Significant post-registration nursing experience
• Experience managing patients with multiple long-term conditions.
• Extensive experience working within community or integrated care services.
• Experience of complex case management in the community.
• Experience working within multidisciplinary teams.
• Experience of autonomous clinical decision making.

Desirable

• Community Matron long term (conditions)/ complex case manager experience.
• Frailty management experience.
• Palliative care experience
• Admission avoidance experience
• Experience managing high intensity service users.

SKILLS, ABILITIES & KNOWLEDGE

Essential

• Long-term condition management.
• Frailty and multimorbidity.
• Admission avoidance principles
• Safeguarding legislation and practice.
• Personalised care planning.
• Community healthcare pathways.

Desirable

• Advanced clinical assessment skills.
• Care coordination and case management skills.
• Leadership and influencing skills.
• Problem-solving and decision-making abilities.
• Ability to work autonomously and collaboratively.
• Strong organisational skills.
• Able to provide one to one teaching and large group teaching
• Problem Solving and decision making

Person Specification
2.EDUCATION, QUALIFICATIONS & TRAINING

Essential

• Registered Adult Nurse with current NMC registration.
• Community Specialist Practitioner Qualification.
• Evidence of continuing professional development.
• Full UK driving licence and access to a vehicle.
• Long term conditions module
• Advanced Clinical Assessment Qualification.
• Teaching qualification or Practice Assessor or Mentorship Qualification

Desirable

• Non-Medical Prescribing Qualification.
• Palliative care module
• Master's Degree or equivalent experience

Experience

Essential

• Significant post-registration nursing experience
• Experience managing patients with multiple long-term conditions.
• Extensive experience working within community or integrated care services.
• Experience of complex case management in the community.
• Experience working within multidisciplinary teams.
• Experience of autonomous clinical decision making.

Desirable

• Community Matron long term (conditions)/ complex case manager experience.
• Frailty management experience.
• Palliative care experience
• Admission avoidance experience
• Experience managing high intensity service users.

SKILLS, ABILITIES & KNOWLEDGE

Essential

• Long-term condition management.
• Frailty and multimorbidity.
• Admission avoidance principles
• Safeguarding legislation and practice.
• Personalised care planning.
• Community healthcare pathways.

Desirable

• Advanced clinical assessment skills.
• Care coordination and case management skills.
• Leadership and influencing skills.
• Problem-solving and decision-making abilities.
• Ability to work autonomously and collaboratively.
• Strong organisational skills.
• Able to provide one to one teaching and large group teaching
• Problem Solving and decision making

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Certificate of Sponsorship

Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the .

From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. .
UK Registration

Applicants must have current UK professional registration. For further information please see

Additional information
Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Certificate of Sponsorship

Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the .

From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. .
UK Registration

Applicants must have current UK professional registration. For further information please see

Employer details

Employer name

Buckinghamshire Healthcare NHS Trust
Address

William Rathbone House

Stoke Mandeville Hospital

Aylesbury

HP12 3RE

United Kingdom

Employer's website