EAST:MK Primary Care Network has exciting opportunity for an ICST nurse into our practice team on a full-time basis, working 37.5 hours per week between Monday and Saturday. Working 5 days on a rotation basis, the successful post-holder will work across our 4 surgeries - Ashfield Medical Centre, CMK Medical Centre, Milton Keynes Village Practice and The Grove Surgery that make up the PCN.
The role of ICST Nurse is to oversee the caseload across the PCN and ensure that service delivery is implemented to the highest standard in line with the NHS Personalised Health and Care Framework. This will include delivery of best practice and personalised care and support planning. The post holder will provide patients with physical and psychosocial assessment and offer support and guidance to the PCN to ensure that patient needs are met through a variety of systems and continue to develop the service in accordance with the needs of the population registered with GP practices within the PCN.
Responsibilities of the role will include:
- Provide integrated personalised care planning and an active case management system for patients of the PCN over the age of 18 years.
- Receive referrals from the 4 practices of East:MK PCN to review patients keeping them safe and well at home.
- Identify those patients at risk of admission by visiting and assessing patients not seen in surgery for a while and to establish functional ability with an aim to assist them to engage in meaningful and purposeful daily tasks.
- Avoid or reduce hospital admissions as well as reducing long waiting times to ensure users are being treated by the best professionals for their need.
- Visit patients with recent hospital admissions/ struggling at home/ not known to other social services and signpost them to the most appropriate support services.
- Liaise with hospital nursing staff to prevent admission from A&E to wards.
- Work with other members of the ICST and Social Worker to review patients and provide a holistic and person-centred assessment working alongside social care and the voluntary sector services.
- Work with the PCN health and wellbeing coaches and social prescribers to review patients.
- Memory assessments.