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Case Manager Job Description
• To be professional and legally responsible and accountable for all aspects of your own work including the management of patients in your care. To ensure a high standard of clinical care for the patients under your management and support more junior staff to do likewise.
• To frequently undertake the comprehensive assessment of patients, including those with a complex presentation, requiring prolonged concentration to investigate and analyse the assessment to formulate individualised management and treatment plans, using clinical reasoning and knowledge of a wide range of treatment options to formulate a specialised programme of care.
• To use continuous assessment to evaluate treatment outcomes and adjust care and treatment plans accordingly, appropriately referring to other agencies to meet patients’ needs and promote integration of services.
• To support clinical advice with reference to evidence base and to experience of complex conditions.
• To be proactive in identifying patients with complex needs within the community in collaboration with all relevant services.
• To contribute towards and promote the coordination of relevant health and social care services in order to optimise patient benefits and reduce the need for secondary care.
• To formulate care plans and oversee their implementation, monitor and review the individual’s ongoing needs and the appropriateness of the service(s) in order to improve quality and access across health and social care, promoting user choice and independence.
• To manage the delivery of care to an active caseload of patients by self and other agencies to reduce the risk of hospital admission and of deteriorating health, using a care plan agreed with patient and carers.
• To contribute to the development and implementation of an efficient review system in accordance with the Principles of Care Planning and in line with all appropriate Quality Requirements in the NSF for LTNC and all other relevant national and local clinical guidelines, technology appraisals or NSFs pertinent to specific pathology groups.
• To negotiate with others around case management in complex cases, agreeing appropriate clinical and professional roles and ensuring a positive resolution to any areas of conflict, in order to ensure the efficient and effective delivery of multidisciplinary care.
• To work as part of an integrated team and together with the service user formulate care and support plans that maximise the individual’s control and choice over how their care needs are met.
• To ensure that clients, carers and families are involved in the planning and prioritisation of their care plans wherever possible, by presenting clinical information in an appropriately accessible format.
• To adapt practice to meet individual client’s circumstances, including due regard for cultural and linguistic differences ensuring that effective communication is achieved particularly where there may be barriers to understanding.
• To adopt a flexible and innovative approach to client work recognising the need to form productive relationships with people who are under extreme stress and / or have significant communication difficulties and / or cognitive and behavioural difficulties.
• To accept clinical responsibility for patient caseload and to organise this effectively and efficiently with regard to clinical priorities and use of time.
• To receive and communicate complex, sensitive or contentious information to patients and carers, who may have barriers to understanding, e.g. dysphasic, complex mental health problems, to maximise rehabilitation potential and to ensure understanding of conditions.
• To have expert verbal and non verbal communication skills of motivation, explanation and reassurance to agree and gain co-operation of patients and carers in their treatment programmes
• To provide spontaneous and planned advice, teaching and instruction to relatives, carers and other professionals in the application of the care plan, and to ensure a consistent approach to patient care and treatment.
• To provide expert advice and opinion to colleagues working within other clinical areas.
• To assess capacity, gain valid informed consent and have the ability to work within a legal framework with patients who lack capacity to consent to treatment.
• To provide services in working conditions, which may frequently be hazardous, e.g. exposure to body fluids, aggressive persons, associated travel risks, high risk areas, and secure units.
• To work with patients, carers, relatives who may have distressing or challenging social/clinical circumstances or behaviour.
• To contribute to the decision making about the treatment, discharge, planning and long term management of individual patients.
• To liaise and co-operate with colleagues in secondary care and social services as and when necessary to effectively co-ordinate patient transfers of care.
• To act as a patient advocate and present their needs and preferences for care when supporting the procurement of services.
• To actively promote the safeguarding policies and follow procedures to protect vulnerable people when necessary.
Organisational-Case Manager Job Description
• Produce reports, documents and proposals often in short timescales to inform service development as and when requested.
• Deciding priorities for own work area, balancing other patient related and professional demands and ensuring that these remain in accordance with those of the section as a whole.
• To be responsible for equipment used in carrying out clinical duties and to adhere to departmental policy, including competence to use equipment and to ensure the safe use of equipment by others through teaching, training and supervision of practice.
• To maintain accurate, comprehensive and up-to-date clinical and non-clinical documentation, in line with legal and departmental requirements.
• To participate in communication events to raise profile and stimulate usage of the case register and LTNC Case Management Service across the range of probable referrers and stakeholders
• To be actively involved in the collection of appropriate data and statistics for the use of the department.
• To be aware of Health and Safety aspects of your work in all community settings and implement any policies, which may be required to improve the safety of your work area, including your prompt recording and reporting of incidents and accidents to senior staff, completing risk assessments and ensuring that equipment use is safe.
• To comply with the organisational and departmental policies and procedures and to be involved in the reviewing and updating as appropriate.
• To undertake any other duties, after negotiation, that might be considered appropriate by the Lead Case Manager and/or Service Manager of the LTNC Unit.
• To work with Lead Case Manager on planning and implementing new services and the modernisation of existing services.
• To attend case management team meetings, activities and working groups to develop staff and services within the health and social care community.
• To participate in the recruitment process for new staff and assistants in relation to the case management service. May be involved in recruitment panels for other professional staff.
• To use judgement in dealing with unplanned crises/issues without direct supervision of senior management, which require investigating, analysing and decision making
PROFESSIONAL-Case Manager Job Description
• To deputise on request for the Lead Case Manager to represent the service on stakeholder groups and forums.
• To participate in research and audit projects to develop services to improve patient care and quality of delivery.
• To make referrals to any appropriate provider to obtain support or resources
• To maintain mandatory training competencies and own clinical professional development (CPD) with reference to current evidence based best practice and incorporate them as necessary into your work.
• To be an active member of the in-service training programme by the attendance and delivery of training sessions at staff meetings and by attending external courses and practising reflective practice.
• To participate in the development and implementation of service changes within clinical area and influencing policy development.
• To communicate effectively and work collaboratively with health and social care colleagues to ensure delivery of a co-ordinated multi-disciplinary service to patients within the complexities of a community environment.
• To participate in the staff appraisal scheme and Personal Development Plan (PDP).
• To participate in the measurement and evaluation of your work and current practices through the use of clinical audit, outcome measures and reflective practice. Make recommendations for change.
• To demonstrate a sound understanding of Clinical Governance, Risk Management and equal opportunities policies and apply to work situation.
Qualifications / Training Recognised qualification in a social care profession
Educated to Masters degree level or equivalent
Evidence of ongoing high-level professional training and development
Experience Evidence of professional development as a qualified social care practitioner or Case Manager.
Significant demonstrable experience of working in a community based environment.
Demonstrable experience of working in, or in close association with, MDTs in a community setting in a statutory or non statutory organisation. This may include work undertaken in the independent sector.
Significant demonstrable experience of working with highly complex packages of care in a health and/or social care environment.
Knowledge Specialist knowledge of the management of patients with a LTNC
Knowledge of relevant Social Care policy and issues, particularly relating to community care.
Knowledge of the complex inter-relationships between health and social care policies and culture.
Specialist social care or clinical knowledge related to the client population.
Advanced knowledge in motivational, influencing and negotiating techniques.
Understanding of the complexities of integrating services.
Knowledge of data management through use of IT
Skills and Abilities
Ability to efficiently assimilate complex information and communicate this effectively at all levels.
Skilled at working in a multi agency setting
Ability to work successfully in an environment characterised by complex change.
Good analytical skills.
Ability to think laterally in complex situations.
Ability to work closely with carer and family systems.
Highly developed communication, motivational, influencing and negotiation skills.
Well developed IT skills including word processing, spreadsheets and presentation packages.
Excellent report writing skills.
Ability to form effective working relationships with a wide range of individuals.
Ability to deal with adverse and possible serious incidents and emergency planning.
Ability to prioritise and apply available resources in the most efficient and clinically effective manner to ensure high quality patient care.
Understanding of public health and health inequality issues.
Excellent organisational ability.
Diplomacy, advocacy and partnership working skills.
Excellent communication, motivational and interpersonal skills.
Commitment to delivering the ORGANISATION Plan, health improvements and a first class community service.
• To exercise a high degree of personal professional autonomy and make critical judgements to satisfy the expectations and demands of the role and to practice within agreed protocols to support the client group to provide a single accessible service.
• To maintain and proactively promote the use of the case register across all service providers f
• To collaborate with all relevant service user representatives on the promotion and use of a case register.
• To maintain the day to day operation of the case register by working in partnership with all relevant health and social care agencies in identifying patients with a LTNC within the community.
• To undertake care planning for patients with a LTNC in the community utilising the skills of all relevant agencies or provider services as required.