Role Overview
The person appointed to this post will work as part of the integrated care programme for older persons is to support older adults to access the assessment and intervention that are required to address increasing health needs whilst being maintained in their home.
This role will co-ordinate the day-to-day functions of the outreach team and work as part of that team as required.
The role involves working across the entire continuum of care for older adults, including community healthcare, networks, and hospitals, as part of a comprehensive ambulatory care strategy.
Provide as a key liaison for referred older adults, facilitating seamless access across Primary Care, Community ICPOP, and Acute services.
Key Responsibilities
Rapid access assessment
Rapid access to specialist assessment and treatment pathways Frailty, Falls, Cognitive pathways
MDT Comprehensive Geriatric Assessment (CGA)
Access to reablement and rehabilitation after acute illness or injury
Complex Case management and care co-ordination
Promotion and support of population health and wellbeing initiatives with primary care
This role entails providing comprehensive support and coordination across the entire continuum of care for older adults within the community healthcare network, it focuses on delivering integrated services that address the diverse health and social needs of elderly patients, from preventive care and early intervention to ongoing management of chronic conditions. The position is a key component of an overarching ambulatory care approach, emphasizing ambulatory services and community-based care to promote independence, enhance quality of life, and reduce hospital admissions. Collaboration with multidisciplinary teams, patients, and their families is essential to ensure seamless care transitions and personalized care plans tailored to the unique needs of everyone.
Clinical Nurse Manager Responsibilities
The post holder will co-ordinate the day to day functions the ambulatory outreach team and work as part of that team as required
The post holder will ensure that team structures are attended to ensure that the service is consistent with recognized best practice in team functioning
While clinical functions are central to the role of liaison, he or she also performs signposting ensuring the provision of a seamless integrated service for the older Adult
The post holder will work with staff in Acute Services ICPOP Hubs, Community healthcare networks and GPs to support the management of older person care needs as close to home as possible and to signpost to the most appropriate specialist clinical service including in the specialist hubs when required
The post holder will coordinate with the clinical teams in the HUBS, working alongside GPs and Community Healthcare Networks
They will ensure that the clinical needs of vulnerable older adults are assessed and managed, including in the specialist ambulatory care hub. Additionally, they will support patients in accessing the appropriate care pathways promptly, ensuring a seamless continuum of care between primary care and specialist services
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