Specialist Neighbourhood Nurse (SNN)

The role of the Specialist Neighbourhood Nurse is to support both the practice staff and members of the Neighbourhood Team to identify and support people to reduce the risk of unplanned hospital admissions and to effectively support those individuals in the community.

To pro-actively engage with people deemed to be at a high risk of hospital admission

To liaise with the registered GP and other practice-based staff in addition to all other providers and services utilising, where appropriate, a multi-disciplinary approach.

To implement and review individual care plans, a self-management plans, CGA assessments, and to agree trigger thresholds to contact Case Managers / GPs.

To ensure all people in Nursing and Residential homes have care plans (including dementia where needed) and to provide a holistic review of all people in these homes with updates of their care plans.

Provide enhanced support to Nursing and Residential home with a focus on strengthening relationships and improving access through information sharing, education and advice.

General duties

Health and Safety- It is the

responsibility of the individual to work in compliance with all current Health

and Safety legislation and the Practice Health and Safety Policy. To attend any

training requirements, both statutory and mandatory, in line with the legal

responsibility to comply with the Health and Safety at Work Act.

To maintain registration with the NMC.

To adhere to the NMC Code.

To support training and development.

To maintain personal professional competency and appropriate

development.

To carry out the duties and responsibilities of the post in accordance

with the Practice Policies including duty of candour and whistleblowing.

Required to comply with all relevant national and local statutory and

mandatory requirements including Health and Safety, Infection Control,

Safeguarding, Information Governance, Research Governance and Equality and

Human Rights.

To implement and review individual care plans, a self-management plans

and to agree trigger thresholds to contact Case Managers / GPs.

Plan visits to housebound people, undertake every 3-6 months, and

arrange care plans where necessary

Provide enhanced support to Nursing and Residential home with a focus on

strengthening relationships and improving access through information sharing,

education and advice.

Planned visits to Nursing and Residential homes to be undertaken every

3-6 months, providing training as required.

To ensure all people in Nursing and Residential homes have care plans

(including dementia where needed) and to provide a holistic review of all

people in these homes with updates of their care plans.

To contact people where necessary to advise them of the role of

Visit people at home following the identification of urgent clinical

need including those escalated by EMAS or a member of the Neighbourhood Team,

undertake a personalised comprehensive assessment, in order to diagnose, treat

and prescribe within the limitations of your registration and competence

Visit people at home following an unplanned hospital admission and those

with a history of repeat admissions, within 2 weeks.

Contact those that have suffered a bereavement.

Arrange dedicated appointments in practice, for those who wish to visit,

with flexibility to expand up to 30 minutes, or as needed.

. Key Responsibilities

Act as a point of contact between GP, Neighbourhood Team, people and

their carers.

Develop and maintain a detailed knowledge of local services to enable

supported signposting of people with identified need, sharing information with

the Neighbourhood Team.

Liaise with GPs and practice teams to identify people who are elderly,

frail or who have long term health needs and support.

Liaise with primary, secondary and specialist care services as required.

Work with the Neighbourhood Team to help identify people at risk of loss

of independence or admission to hospital as a result of inadequate social

support.

Provide these cohorts of people signposting to identified services in

order to maintain their independence and improve their health and well-being.

Visit people in community, home or care home settings to assess and

discuss their care needs involving carers as appropriate.

Implement personal care plans for individual people, ensuring

preventative actions are detailed to support the appropriate use of services.

Communicate the care plan to the GP and any other members of the

Neighbourhood Team involved in the persons care and upload to the relevant

records.

Ensure that identified people receive the right level of help at the

right time and help them to experience a joined-up service by liaising with

relevant members of the Neighbourhood Team.

Work with patient, carers and the Neighbourhood Team to encourage the

patient to adopt effective self-management and self-help seeking approaches to

reduce unnecessary hospital admissions.

Liaise with other agencies to ensure timely and appropriate engagement

as required.

Support people to access community care assessments as well as carers

assessments.

Where a personal healthcare budget is allocated provide advice as

required regarding the key choices the patient will need to make.

Identify unpaid carers and direct them to access services as appropriate

to provide them with support.

Identify when urgent action or a step up in care is required and

promptly alert the relevant member of the Neighbourhood Team, highlighting any

safety concerns.

Follow up on communications from out of hospital and in-patient services

regarding changes in condition of people to support the practice to respond

proactively to potentially unmet needs.

Undertake visits or telephone contact to manage people on the SNNs case

load following any unplanned hospital admissions where appropriate.

Participate in Practice multi-disciplinary meetings to discuss Practice

people actively being managed by the Neighbourhood Team and any other people

from the SNNs case load needing discussion.

To attend Neighbourhood Team MDT meetings at the Practice plus any other

meetings where there is a need to discuss Practice patients.

Undertake visits or arrange appointments at the Practice for people on

the SNNs case load or otherwise as directed by the Duty Doctor following

identification of urgent and non-urgent clinical need to assess, diagnose,

treat, prescribe and refer appropriately according to the patients health

needs and acting within the SNNs clinical skill set.

Maintain accurate and up to date records of patient contacts using GP

record systems and other IM&T systems relevant to the role i.e. entering

notes onto Systmone / EMIS using agreed read codes and VMDT

To run regular patient searches using Systmone / EMIS in order to have

an up-to-date record of progress of achievement of Key Performance Indicators.

Work with South Lincolnshire ICB, Neighbourhood Teams and other agencies

to support and further develop this role.

Support the Practice Manager in providing KPI reports for submission as

requested.

5. Key Working Relationships

Practice teams

Neighbourhood Team

Community health services

Specialist teams heart failure, diabetes etc.

Specialist nursing services e.g. St Barnabas

Hospital teams including ward, A&E, discharge and AIR teams

Health & Wellbeing Coaches

Safeguarding agencies

South Lincs Rural PCN is made up of 9 practices: The Suttons, The Deepings Practice, Bourne Galletly, Holbeach Park Road, Littlebury Medical Centre, Abbeyview Surgery, Moulton Medical Centre, Gosberton Medical Centre and Sutterton Medical Centre.

The development of Integrated Neighbourhood working is supporting

Providers to work in a joined-up way. and Primary Care plays a key role in the

success of Integrated Neighbourhood working, supporting patients to self-manage

their condition or be assisted to manage their health needs closer to home, in

their local communities. This approach enables more people with health and

social care complexities to achieve a greater balance in all round health.

Knowledge and skills

Experience

Desirable: - Experience of working in Primary Care; - Experience of working in a GP practice

Qualifications