Job summary
An exciting 12 months Secondment Opportunity has a risen for the position of a Spinal Case Manager
The role entails managing your own caseload, leading on the safe, effective discharge from the centre of highly complex spinal cord injury (SCI) patients through close liaison with the wider SCI MDT.
Ensure national and locally agreed targets are met through the co-ordination, organisation, planning and chairing of patient's goal planning meetings to enable realistic and achievable clear patient goals with appropriate timeframes are agreed and actioned by the wider MDT.
Negotiate and liaise with external stakeholders including CHC, CCGs, Local Authorities, Social Services, Nursing Homes and Care Agencies to ensure safe and timely discharge.
The post holder will ensure the key functions of case management, they will be responsible for the management of allocated patient caseloads, responsible for day to day running of the case management team in order to ensure effective implementation of Case Management Services for the RSIC.
Interview Date - To Be Confirmed
Main duties of the job
To provide highly specialised advice to guide staff, patients, carers, and families through the rehabilitation process pathway to enable, safe, timely discharge from the Centre.
To facilitate and co-ordinate training of primary care staff to provide care needs to individual patients with spinal cord injury to facilitate discharge.
To ensure robust and accurate records are maintained at all stages of the patient journey.
To be a pivotal role and communication channel for relatives and significant others of patients admitted to Centre.
Ensure compliance with the requirements of the Health and Safety of Work Act (1974).
Assist the Matron in ensuring the service complies with the CNST Standards and Risk Management Strategy.
Ensure dissemination of information to members of the Case Management Team and feedback via appropriate forums.
Promote and deliver effective lines of communication through team briefing as a second level briefer.
Inform admission meeting to ensure optimum utilisation of available beds.Deputise in absence of Spinal Nurse regarding bed management.
Inform admission meeting to ensure optimum utilisation of available bed.
About us
Mersey and West Lancashire Teaching Hospitals NHS Trust serves a population of over 600,000 with a workforce of over 9000 dedicated and skilled staff across 21 sites.
We strongly believe that the communities we serve should all have access to Five Star Patient Care.
Our Services:
Acute Care
Providing emergency and maternity services at Whiston, Southport and Ormskirk hospitals, and medical and surgical specialties across all our sites.
Primary Care
Providing primary care services at Marshalls Cross Medical Centre situated in St Helens Hospital.
Community Services
Providing adult community services for St Helens and a wheelchair service in Chorley, South Ribble, and West Lancashire. Our inpatient unit at Newton Community Hospital is where patients needing acute hospital beds can continue rehabilitation, freeing up space for more unwell patients. We also provide urgent care at our Urgent Treatment Centre located in St Helens town centre.
Specialist Regional Services
We provide the Mersey Regional Burns & Plastic Surgery Unit at Whiston Hospital and the Spinal Injuries Unit at Southport Hospital to more than 4 million people across the whole of Merseyside, West Lancashire, Cheshire, Isle of Man and North Wales.
Achievements:
o Rated Outstanding by CQC Inspection August 2018
o Top 100 places to work in the NHS (NHS Employers & Health Service Journal)
o National Preceptorship Accreditation (2023) for Nursing & AHP Preceptorship Programme
Job description
Job responsibilities
KEY DUTIES
To promote effective communication throughout the Centre and with external organisations and be able to respectfully challenge the MDT and negotiate change to advocate for the patient.
Attend departmental meetings as appropriate to ensure effective communication and performance across the Centre.
To promote a critical, analytical approach to monitoring the progression of highly specialist patient rehabilitation against rehabilitation goals, obtaining relevant patient care information to support completion of Centres Discharge Pathway.
Implement, review and support the development and introduction of new pathways and processes to develop the service.
To continually evaluate and develop the role and service, formulating reports and patient information for dissemination.
Undertake specific projects within the Service Group as requested by the Spinal Specialist Nurse and Matron.
To propose and Implement changes to practice, policies and procedures in own area and propose policy changes and impacts in wider area.
Formulate professional documentation to support care plans at discharge for care commissioners, care providers and District Nurses.
Act as the main point of contact and support for families of patients admitted to the North West Regional Spinal Injuries Centre.
Initiate and participate in the promotion of health education for all patients.
To work autonomously at a level of specialist practice to ensure the smooth co-ordination of rehabilitation through liaison with the MDT, patient and families.
Ensure all patients follow the Trusts discharge pathway and that appropriate legislation is adhered to.
Work with the MDT and Directorate Manager to reduce length of stay and reduce delays in accordance with the Centre and NHS England targets.
Use paper and electronic records to record data relating to patients rehabilitation timescales and discharge.
To value and respect individuals showing reassuring sensitivity when dealing with patients and families, actively promoting the Centre and the Trusts core values.
To contribute to the development of standards of practice that reflects safe patient flow through the Centre and work to local and national standards.
To assist the Centre in the development, implementation, evaluation and monitoring outcomes.
To assist in achieving performance targets, collect data and contribute to the performance reports as required.
Utilising a range of software applications, ensure patient records are maintained and discharge pathway updated to enable the wider MDT to understand where the patient is on their rehabilitation pathway
CLINICAL & PROFESSIONAL RESPONSIBILITIES
Manage patients case load providing and receiving highly complex sensitive information utilising tact, diplomacy, high level of communication skills often in a highly emotive atmosphere and managing the link between the Centre and community services.
Co-ordinate Continuing Healthcare Assessments. Advocating for the patient using specialist knowledge underpinned by theory and providing a recommendation to local CCG commissioners.
Utilise analytical and judgement skills to make decisions on complex issues relating to discharge planning, adhering to legislation and Trust policies.
Work closely with Consultants, Nurses and Allied Health Professionals around rehabilitation plans to facilitate safe and timely discharges.
To identify barriers, gaps or trends that impact the discharge pathway and resolve to ensure effective rehabilitation processes and safe and timely discharge.
To analyse and report on patient discharge process throughout the pathway highlighting key areas of concern.
Liaise with appropriate personnel to ensure clinical activity of the rehabilitation process supports the estimated discharge date.
To provide specialist advice to patients, community staff, carers, healthcare assistants and students demonstrating expert knowledge of services regarding highly complex rehabilitation.
Provide the first line psychological support to patients and their families, escalating to the Clinical Psychologist as appropriate.
Empower patients to make informed choices regarding their rehabilitation and reintegration.
Advise patients on the availability and limitations of community resources.
Act as an advocate for the patient throughout the discharge process.
Work with the MDT to ensure all patients have up to date goals, assessment, equipment ordered and progress reports to inform discharge care plans.
Gain current information from the MDT to create professional documentation to support care plans at discharge for care commissioners, care providers and District Nurses.
Ensure adequate environmental facilities, equipment needs and care provision for those with highly complex care requirements.
Provide an oversight and resolution of any issues relating to specialist equipment, procedures and care that would delay the delivery of rehabilitation or discharge planning.
Participate in MDT ward rounds and caseload review to assist in the planning of individual patient pathways and provide an overview of patient flow and discharge plans to MDT.
To ensure effective communication of highly complex clinical information with staff, patients and other agencies, as necessary, requiring in-depth knowledge of speciality and discharge processes and may include highly contentious, sensitive and delicate issues with patients and their relatives and staff.
To use clinical reasoning to make operational judgements to manage conflicting views and reconcile professional differences of opinion.
To demonstrate persuasive motivational skills in dealing with difficult communication issues and encouraging co-operation with rehabilitation and discharge plans.
Co-ordinate weekly multi professional discharge planning/goal planning meetings.
Ensure every patient allocated to caseload has a realistic, achievable estimated discharge date and ensure review of this date throughout patients journey.
Support patient and families and provide links to appropriate available support network.
To co-ordinate and lead on, own case load, identification of correct funding streams for care provision for patients registered within the Centre.
Co-ordinate requested weekend leave for patients.
Liaise with the Intermediate Care Team to facilitate intermediate discharge from the NWRSIC.
Participate in regular ward rounds with the Ward and Intermediate Care Teams to ensure effective communication is maintained.
RESEARCH & AUDIT
Ensure compliance with all Trust Research Governance procedures.
Participate in research activities carried out by North West Regional Spinal Injuries Centre.
Maintain an awareness of current research and participate in the dissemination of research findings.
Undertake specific Case Management audit and research, promoting effective processes and present at Journal Club.
Participate in the NWRSIC annual audit programme
Work closely with the Data manager to develop and ensure data collection is effective, informs practice and identifies any trends or areas of concern.
TEACHING & TRAINING RESPONSIBILITIES
Provide specialist advice to patients, community staff, carers, healthcare assistants and students.
Co-ordinate training for members of community-based teams within the catchment area of the
Centre to care for patients with spinal cord injury to support discharge of own case load.
To regularly review own practice against the national spinal services standards.
To provide ongoing support and education to new members of Case Management Team and members of the wider MDT.
To undertake Patient Education sessions ensuring patients are educated aroundrehabilitation journey and discharge.Person Specification
Qualifications
Essential
Qualified Healthcare Professional such as RGN or AHP
Post registration Spinal Injuries Course or equivalent experience Level 4
ECDL or equivalent experience
Desirable
Leadership qualification at level 3 or equivalent experience
Masters module in complex rehabilitation (Level 7) or equivalent experience
Knowledge & Experience
Essential
Experience within spinal injuries or equivalent
Specialist knowledge across a range of processes relating to discharge planning, rehabilitation, ventilation and SCI care needs.
Understanding of case management processes and the complexities of community-based patient care
Experience of communicating complex issues
Desirable
Experience with patients requiring long-term ventilation.
Experience negotiating with outside agencies on care issues.
Experience of leading a team
Skills
Essential
Excellent communication skills both written and verbal.
Good computer skills
Ability to learn new techniques.
Understanding of outside agencies working environment.
Ability to guide patients and family through rehab process pathway
Judgement and critical decision-making skills
Ability to manage highly complex, sensitive information in a highly emotive atmosphere
Planning and organisational skills
Ability to respectfully challenge the MDT and negotiate change to advocate for the patient
Maintain accurate documentation and record keeping
Ability to undertake audit
Willing to undertake clinical development within the speciality
Willing to develop self in new techniques in spinal cord injury management appropriate to role
Desirable
Ability to take responsibility to hold to account
Ability to provide highly specialised advice and guidance
Ability to challenge existing processes
Ability to undertake presentations to staff and patients
Other
Essential
Office based role with the requirement of travel to external Providers and Agencies.
Car driver / owner (business use insurance applicable) or the ability to travel within a reasonable timeframe
Flexible approach to working hours
Ability to withstand the pressure of work
Frequent concentration whilst subject to interruptions from colleagues, external agencies and patients
Sensitivity to the needs of disabled patients, relatives and staff, particularly those working outside their normal area of care
Frequent exposure to distressing or emotional circumstances
Primarily an office-based role/VDU use
Frequent exposure to aggressive or abusive behaviours from patients and relatives
