Band 7 Guided Care Matron (CCT)NHS

Job summary

Are you caring, compassionate and committed to delivering patient-centred care? An exciting opportunity has arisen for a nurse working as a band 6 or 7, who are looking for a new challenge or to progress to a Guided Care Matron. In Hillingdon we are transforming our model of case management as part of the North West London - Integrated Care model. You will work as part of a Care Connection Team (CCT) in Hillingdon, providing anticipatory care to patients to prevent escalation of their health and or social care needs, thereby reducing the risk of emergency hospital admissions.

Main duties of the job

The service works with patients over the age of 18 years with one more or of the following conditions; COPD, Stroke, Cardio Vascular Disease, Dementia, Social Isolation and Diabetes Mellitus. You will work to develop care plans for the patients on the CCT caseload, and proactively seek to identify at risk patients. You will be part of a once weekly huddle meeting with each of your CCT's, to discuss patients on your caseload and formulate their care plans. Where appropriate, you will make referrals to key stakeholders such as other community services e.g. district nurses, geriatrician, social services and third sector.

Job description

The GCM will work closely with GPs to proactively identify patients (aged 18+) with high risk complex needs. They will provide a proactive, holistic approach to managing patients with long-term conditions that is centered on primary care and the prevention of avoidable hospital admissions. The focus will be on providing comprehensive assessments, individualized care plans and coordination for complex patients in their usual place of residence including care homes. The GCM will enable the patient, carers/care home staff and families to understand their disease or condition, how to recognize early symptoms and proactively manage their care decisions. The GCM will work as part of a multi- disciplinary team and will develop care plans for the patients on the Care Connection Team (CCT) caseload, supported by the CCT. GCMs will attend once or twice weekly huddles with the CCT to discuss patients on their caseload and formulate care plans. Where appropriate, referrals will be made to key stakeholders such as other community services e.g. district nurses, geriatrician, social services and third sector. The distance nurses travel each day is considerable and the GCM nurses use of their own car to carry out their domiciliary visits. The GCM works autonomously to provide a full range of services predominantly to house bound patients including residential and nursing homes and will be skilled in carrying out Holistic assessments.

About us

The distance nurses travel each day is considerable and you will need to use a motor vehicle to carry out domiciliary visits. You will work autonomously to provide a full range of services predominantly to house bound patients including care homes and supported living, and will be skilled in carrying out Holistic assessments. The role also involves managerial aspects such as attending key meetings and supervision of junior staff such as Healthcare Support Workers, Senior Administrative Co-ordinators and Student nurses.