Community Matron Bury Rural INT

JOB PURPOSE

To co-ordinate care provision through a case-management approach for a defined high risk patient group with complex long-term conditions (such as COPD, diabetes and CHD) with the aim of preventing unnecessary hospital admissions and facilitating timely discharge. To provide the highest standard of clinical care by using advanced skills and expert knowledge to holistically assess needs and instigate and provide clinical treatments based on evidence-based practice. To participate in the delivery of educational programmes to patients, carers and Health & Social Care workers that promote self care principles. To develop and promote robust multidisciplinary working across the wider Health and social Care sectors to ensure integrated services and support networks for patients. To monitor the quality of care provision and to identify and promote areas for service development.