Interim LD Nurse

The post holder will be required to provide expert advice and identify appropriate providers to address the needs of complex individuals. The post holder will be required to attend Multi-Disciplinary Meetings, Acute Care Facilities, individual’s homes and a variety of care providers. The role will be required to regularly review individuals in line with The National Framework for NHS Continuing Healthcare and to present comprehensive written reports providing assurance to the CCG that the agreed placement is delivering identified needs and it is appropriate to continue commissioning the care plan. They will also be responsible for negotiating care costs and approving these for payment. Support the CHC Head of Service & CHC Lead Nurse in ensuring appropriate individual placements provide safe and high quality care.

Key Relationships

• Continuing Healthcare Teams
• CCG/STP Commissioners
• Local Authority
• Patients & Families
• Provider Trusts – Acute & Community Care Homes
• Community Care Providers
• Finance Department
• NHSE/I

Principal Duties and Responsibilities

The post holder will be required to provide a high-quality resource of professional advice, guidance and expertise to members of the Individual Care Team, CCG and wider health and social care economy. Autonomously manage a case load of individuals with highly complex health needs providing significant clinical guidance to providers. Ensure that all assessments are holistic in nature and utilise The National Framework for NHS Continuing Health Care. To have an expert level of knowledge regarding The National Framework and its application in practice. To be able to impart this knowledge to a variety of audiences. To provide complex and sensitive information to patients, relatives/representatives and often work in potentially hostile environments; relaying difficult decisions regarding care provision and managing patient and family expectations. Provide continuity of care throughout the period of care and support. This will encompass close working with health and social care professionals and care providers. Attend all meetings related to the patient which may impact on the care provision and costs to meet identified needs. Liaise with multiple professionals involved in the patient’s care to ensure that a comprehensive understanding of all identified needs is available. Ensuring that each patient has a care plan that addresses all their identified needs and can be used to assist assessors when completing CHC assessments/reviews. Present comprehensive written reports to CCG Eligibility Panel following any reviews completed once patients are in receipt of agreed care provision that identify a change in the level of care required. This includes being able to demonstrate improvements that may result in a reduction of care provided or a change in the patient’s eligibility for NHS CHC. To be responsible for negotiating care package costs and the monitoring of packages of fully funded care which are in excess of £1000 per week. To be responsible for ensuring these care packages are reviewed to an agreed time scale, identified by the Head of Service and that these are recorded on the CCG database. Identify and process any safeguarding and quality of care issues and take appropriate action to ensure that people’s welfare is protected and that the quality and standard of services provided are at a level that is in line with CCG required standards. Close liaison with the CCG Quality Team is necessary to ensure CCG funded individuals are in receipt of high quality, safe care. Ensure Mental Capacity Act is considered and ensure relevant processes are followed e.g., Best Interests, DOLs. Develop and maintain effective working relationships with clinicians, general practitioners and providers in order to ensure continuity of care and address patient needs. Provide a high quality resource of professional advice, guidance and expertise to the CCG and partner agencies in addressing the needs of individuals with complex health needs. Liaising with a variety of providers and arranging assessment of patients in order that the most appropriate placement/provider is identified. Provide information and support to the senior managers when considering the most appropriate provider to address a patient’s identified needs and to act autonomously when required to agree care packages in excess of the usual CCG cost. To maintain a formal record of all cases and ensure that all relevant clinical information is available and updated regularly, both electronically and in patient files. Support the Head of Service in working with partner agencies and other stakeholders in developing the local market for services to ensure that it reflects the requirements of individuals and is able to meet current and future needs. To call and chair multi-disciplinary meetings, including case conferences and discharge meetings to ensure continuity of care across agencies; thus improving patient and family experience. Deputise for the Lead Nurse as required. Provide data in order that the CCG can continuously monitor care delivery and identify how performance of providers can be improved. Working closely with colleagues in the CCG Quality Team to assure the quality of care received by NHS funded individuals. To have budgetary monitoring responsibilities and to ensure that the Head of Service is informed of any identified budget pressures or financial risks that may impact on the overall service budget. The post holder will need to demonstrate both quality of care and value for money in all placements. To develop policies and procedures, as requested, which will support the overall delivery of NHS Funded Care within the CCG. To contribute to and deliver training on CHC and FNC to a variety of audiences particularly in health and social care. To provide professional support and mentoring to the nurse assessors within the team and provide additional support and training as required by the Lead Nurse. To work within the NMC Code/Professional Code and to meet requirements for revalidation. To undertake and comply with all mandatory training.