Detailed job description and main responsibilities

The COPD Community Matron / case manager will be expected to achieve the competencies set nationally by Skills for Health 2005 (www.skillsforhealth.org.uk). These can be summarised as follows;

• To be responsible and accountable for providing expert care to COPD patients who are registered with a Greenwich GP
• Utilisation of advanced clinical skills and expert knowledge to plan, implement, monitor and review individualised patient-directed programmes of care to patients with COPD including health promotion interventions.
• To undertake goal centred interventions that are evidence-based, evaluating the effectiveness of these at regular intervals with a view to improving care continuously.
• Develop risk management plans that will enable individuals to remain safely within their homes
• Use expert knowledge and skills as a non medical prescriber to manage patient medication within own areas of competency, developing clinical management plans in partnership with GP colleagues where necessary.
• Anticipate individual care needs and develop appropriate care plans, involving carers and relatives
• To provide individuals and their carers with the necessary education that will enable them to plan for unavoidable disease progression and self manage as far as possible.
• To work collaboratively with members of the multi professional team to ensure that the patient’s needs are met, making appropriate referrals are made where necessary.
• Develop practices which promote patient choice and well-being
• To be responsible for ordering stock and other resources when asked
• Ensure that the needs of individuals who are vulnerable are highlighted and addressed in a timely manner
• To be a competent clinical leader demonstrating a willingness to work as an integral  part of a multi professional team
• Be a highly skilled communicator, written and verbal, with a capability for communicating within a variety of professional groups, challenging attitudes where necessary
• To manage a caseload of patients with COPD (Specialist community matron/case manager)
• To practice at an advanced level demonstrating an in-depth knowledge of all aspects of the management of COPD that is evidence-based
• To undertake advanced physical and social assessments and examinations, and initiate appropriate diagnostic activity and treatment
• To work with other community matrons/case managers to ensure a consistency of approach to patient care and to support clinical supervision arrangements within the Trust
• To work collaboratively with other specialist and multidisciplinary teams, such as GPs, District Nurses, Consultants
• To support the and COPD self management programmes such as GRACE and pulmonary rehabilitation
• To contribute towards reducing frequent admissions and bed days of patients with COPD
• To help improve the diagnostic rate of COPD in primary care supporting the delivery of an ARTP accredited quality assured spirometry clinic.
• To work alongside the clinical lead in the new/confirmed diagnosis of COPD in producing treatment plans including self-management and education at consultant lead MDT sessions
• To participate in the delivery of education sessions on the Greenwich Respiratory Advice and self-Care Education (GRACE) programme in a community
• To be confident in the delivery of educational topics including: pathophysiology of COPD, COPD medications, managing exacerbations, breathlessness, productive cough, anxiety and low mood and the importance of exercise and a balanced diet
• To participate in the delivery of pulmonary rehabilitation with the support of the pulmonary rehabilitation lead
• To participate in disease specific audit and data collection
• To act in accordance with the clinical governance framework within the Trust
• To share knowledge and skills with patients and families as a key therapeutic intervention and to enable self care and autonomy
• To identify the educational requirements of primary and social care colleagues in relation to the management of COPD and lead on meeting these needs
• To participate in clinical supervision, appraisal and personal development programme
• Ensure own professional development and clinical skills through attending courses, workshops and conferences and applying the knowledge gained in clinical practice
• To interface with primary and secondary care teams to enable the implementation of managed care pathways in line with local and national guidance
• To advise on and develop new initiatives and ways of working informed by local and national policy
• To be involved in the development of guidelines, policies and protocols within the Trust
• To promote effective collaborative working relationships with health and social care colleagues and those within support networks and the voluntary sector
• To act as a change agent and innovator, planning, instigating and evaluating changes
• To proactively demonstrate the positive impact of case management on the reduction of avoidable admissions and lengths of hospital stay
• Contribute to the service development within the Trust in line with national strategies particularly the COPD
• To maintain accurate and legible and timely records
• To act as leader, mentor and preceptor to staff within the Trust