B7 Community Matron​/Paramedic Response Services

The post holder will proactively manage a caseload of patients requiring complex case management in order to prevent hospital admissions and facilitate early discharge to improve patient health outcomes. Patients requiring case management in the H@H AND UCR Service will be identified by case-finding in the Ambulatory Emergency Care (AEC) unit, Accident and Emergency Department, Whittington Health wards, North Middlesex Hospital A&E, ULCH @home, LAS, Care Homes, Community Nurses and via GP referral.

Patients will be identified as not requiring hospital admission but need high acuity Community support to go home safely.

Working autonomously, the post holder will have continuing responsibility for proactively monitoring and managing patients on the caseload. The post holder will be expected to develop skills in physical assessment, diagnostic reasoning and nurse independent prescribing and use these both in the community and ambulatory care centre setting. Using these skills will assist in the recognition of early symptoms of disease exacerbation, acute illness and injuries.

The post holder will be expected to co-ordinate care and navigate the patient through pathways across the primary, secondary care interface, including the prevention of unnecessary admissions, facilitating appropriate ones through in-reach case finding in both the hospital settings also via Community referral.

• o Facilitate the early discharge of patients from the Whittington Health and NMUH inpatient wards and complete their recovery in the home environment by working collaboratively with the AEC Consultant.
• o Be aware of and utilise appropriate resources within the H@H AND UCR team and in the provision of total patient care. Managing the team on a day-to-day basis, supporting junior staff with decision making and skills development.
• o Undertake a comprehensive baseline assessment for each identified patient in conjunction with the AEC consultant, patient, relatives, carers and patient care team.
• o Use the assessment to agree and implement a patient held personalised plan of care to be agreed with the patient, relatives and carers and the patient care team.
• o Ensure that there are effective communications with other agencies about care plans to support patients at home.
• o Undertake prescribing as required and to ensure that medications are reviewed and highlight possible interactions and changes
• o Perform and document examinations to support proactive monitoring of chronic diseases and identification of early symptoms of exacerbation and liaise with the MDT
• o Work with the AEC consultant, ward consultants and/ or General Practitioner and patient care team to facilitate this and reduce hospital admission.
• o Lead by personal example of best infection control practice at all times.

Our values underpin everything we do. Our staff are committed to delivering the following values in everything they do.

Our ICARE values have been created by our staff and are embedded in our appraisal and planning processes and form part of our staff excellence awards.