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Detailed job description and main responsibilities

MAIN RESPONSIBILITIES

Clinical

To be professional and legally accountable for all work undertaken. To work within the standards and guidelines of the trust, the team, professional services, and appropriate professional body.

To stay up-to date with new emerging evidence and evidence-based practice for frailty and long-term conditions and be able to utilise this to continue to develop the service going forward.

To undertake advanced assessment of people with frailty who present with complex multi-pathology amalgamating in both physical and mental health presentations. To undertake joint visits with all multi-disciplinary team members where appropriate and provide specialist advice on treatment / management regimes.

Comprehensive subjective history taking - supporting the individual to only have to tell their story once - enhancing client experiences and promoting integrated working. 

Completing outcome measures and recording on appropriate systems. 

To formulate, evaluate and reassess individualised management and / or treatment plans, using clinical reasoning and utilising a wide range of treatment skills and options in order to formulate a personalised care plan.

To complete assessments and interventions in a variety of settings utilising a range of methods to do this e.g., face to face and virtual, the clients home and in community settings. 

To be able to manage a caseload of people with complex health and social care needs.

To provide specialist advice for clients, their families and colleagues based on up-to-date theoretical knowledge and relevant practical experience, and provide specialist advice and guidance to MDT colleagues, junior team members and other health care professionals both within and outside the trust.

To use collaboration and partnership to empower patients to effectively self-manage their condition and identify those that may need alternative support to achieve this.

To be able to identify when a client can be discharged from the service, taking into account their confidence and competence to self-manage and to be able to effectively communicate this to the client and their support network.

Ensuring crisis and escalation plans are in place to support client and their support network post discharge.

To be responsible for the maintenance of accurate written records using electronic patient notes. This includes communicating to other health professionals in a contemporaneous manner.

To ensure that high standards of clinical practice and patient care are maintained and to ensure that other clinicians in the team do likewise, through ongoing competency assessment and supervision/appraisal.

To identify appropriate patient cases, present and discuss these the appropriate MDTs, identifying risks to ensure that the wider MDT are aware and involved in decision making. Supporting more junior staff members with this process.

To triage referrals into the team with appropriate clinical experience and supervision and identifying if appropriate or not. To be able to establish priority and assign to appropriate pathway.

To attend and actively participate in MDT clinical meetings and take part in MDT teleconferences to support with multi professional discussions

To use specialist knowledge to refer to other disciplines as appropriate for both physical and mental health support.

To ensure that the service provided is client centred, that all verbal and written information is accessible and understandable to users, considering cultural, sensory, cognitive and behavioural needs.

Leadership 

To support, supervise and appraise the work of supervised staff, students, and rehabilitation assistants / care navigators and to induct new staff as required.

To participate in the Trust Appraisal Scheme, both as appraisee and as an appraiser.

To assist and support the Clinical Leads and service managers, taking an active part in patient engagement, audit and project leading when required.

To be involved in the recruitment, selection, and induction process for staff in the  MACCT / Proactive care service. 

To support staff to achieve and maintain appropriate levels of education and continuing professional development, maintain and update a Continuing Professional Development Portfolio (CPD), are up to date with mandatory training.

To assist in the organisation and presentation of In-service training to staff in the team and wider MDT.

To supervise undergraduate students as required and to liaise with academic institutions regarding student performance and placement within the team.

To establish and maintain robust and effective lines of communication within the MACCT  but also with other stakeholders, including publicising and promoting the service.

In line with the Trust’s commitment to Clinical Governance, to identify and participate in quality improvement (QI) within the team alongside clinical audit and evaluation of clinical effectiveness.

To be responsible for equipment used in carrying out duties and to adhere to departmental equipment policy. To ensure that all equipment defects, accidents and complaints are reported to the team lead and appropriate actions taken as per trust guidelines.

To ensure the competent and safe use of equipment by other designated team members, patients, and carers.

Communication/Collaboration

To work collaboratively with members of the Anticipatory care network and other clinical specialities, e.g. GP practice, palliative care teams, in order to provide seamless, high quality care

To work in partnership with members of NCL & ACS Anticipatory Care teams to assist in the development and review guidelines and protocols.

To develop and maintain collaborative relationships, partnerships and networks to influence and improve the delivery of MACCT / Haringey Anticipatory Care. 

To contribute to the development of formal mechanisms to share good practice across Whittington Health and elsewhere sharing knowledge, skills and clinical expertise.

To maintain patient information systems in a timely and professional manner and in line with local guidelines and protocols.

To provide specialised advice, teaching and training to other members of the MDT regarding the Occupational Therapy management of adults in the community.

Research/Audit

To be proactive in local and national audits in order to assess the effectiveness and productivity of MACCT/ Haringey Anticipatory Care and service provision.

To participate in and critically evaluate research findings, to disseminate them appropriately and implement findings to improve the service and patient care

To participate in research appropriate to the role.

To provide regular information and statistics to assist in the audit of the service and respond to the needs identified and in keeping with national standards / guidelines.

Note:  this job description is a reflection of the current position and the post holder is expected to view it as a guide rather than an exact description of all duties and responsibilities.  It may be varied from time to time in consultation with the post holder.