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Detailed job description and main responsibilities

Intervention and management of a case load of patients, working as a specialist practitioner working to pro-actively monitor and anticipate changing phase of illness and health and social care needs of patients with serious mental illness.

To ensure delivery of a person centred approach, “What matters to me” to all patients that enables individuals to achieve their optimum physical, psychological and social wellbeing. Being an advocate for the patient in ensuring they receive appropriate timely care.

Act as a specialist practitioner, working with a caseload of people referred to them in a manner which demonstrates a specialist knowledge base and specialist clinical skills and competencies.

Improve clinical outcomes for patients by enabling them to function independently by increasing their choice to remain in their own home / community and reduce the need for, or prevent inappropriate hospital admission

Triage, initial assessment , management and prioritisation of a caseload of patients according to their health status, who are referred by various agencies including GP, hospital, case managers, social care, and independent sector promoting self-care, self-management and independent living.

Contribute to the work carried out by Neighbourhood colleagues from a MH perspective.

Provide coordination and oversight supporting the management of people with low level mental health issues (Primary Care Therapy Colleagues/community assets support)

Establishing effective working relationships with patients, their families and carers including education and promoting individual rights, recognising and respecting their contributions to care planning, placing patient in the centre of their care. Referral on to the appropriate support, ie medical, mental health, physical health, third sector, well-being or social prescribing.

Develop individual evidence based holistic care plans and self-management plans with the patient, carers, relatives, health and social care professionals. Recognising the differing phase of illness and planning for deterioration.

To support GP’s by providing advice, direct input and where necessary primary care mental health assessment to inform intervention of appropriate secondary services

To work with people requiring support, primary care mental health support workers and social prescribing link workers to set outcomes and objectives, develop, implement and review support plans

Clinical leadership & expertise of wider team (Primary Care Therapy Roles, Community Development Officer, neighbourhood team colleagues).

Attends core neighbourhood working meetings as part of an integrated team and works in a collaborative manner with the Neighbourhood Lead.

Facilitate, participate and optimises case conferences / multi-disciplinary team (MDT) meetings. Establishes and maintains excellent trusted and credible relationships with individuals and groups, exploring issues relating to care options and decisions to sustain effective working across the health social care and voluntary system.

To work within the Mental Capacity Act and safeguarding policy. Refer to social services as per adult protection policies and complete all appropriate documentation

Maintain and record accurate documentation and correspondence in line with professional and Trust guidance in the appropriate legal records and formats.

Plan, implement, monitor and review therapeutic interventions with individuals / carers who have serious mental illness through holistic patient centred assessments.

Support the local implementation of national and local policy that impacts upon the health and well-being of patients such as the NHS England framework for community mental health services.

Act as a role model and expert to neighbourhood colleagues, endorsing best practice, policies, procedures and guidelines to ensure risk assessments are completed for the environment in which the team is working .

Develops and maintains highly developed clinical skills and support the learning and educational needs of others within the neighbourhood.

Engages patients and carers in individual health promotion action.

Participation in population health / management / improvement activities within the community and use high level communication skills to communicate complex issues with patients and carers, in particular the skills needed for cognitive assessment and mental health status.

Maintains patient confidentiality and works within the confines of the Data Protection Act

Undertake medicine management review and prescribe medicine and appliances for patients.