Detailed job description and main responsibilities

Key Result Areas & Performance:

1.    Provide clinical leadership for the core INT team and support the Principal Pharmacist to develop the service to meet the needs of the PCNs and wider Lewisham INT model of care.

2.    To supervise other non-clinical staff within the INT core team, including 1-2 caseworkers, link worker and health coach within the Neighbourhood for which responsible.

3. To deliver patient facing care and conduct multi-morbidity reviews to improve outcomes for patients with complex needs or provide support before needs become acute. 

4.   Participate in clinical audit to support evaluation of service delivery and inform improvement. 

5.   To work closely with other members of the core INT team including link workers, key workers, health equity team, GPs and community groups, linking with clinicians and staff within other community and secondary teams within both health  and social care to ensure a holistic and multidisciplinary approach to care maintained.

6.  Provide medicines management expertise and support to patients, other clinical and non-clinical staff as part of the INT model of care. 

7.  To practice and promote appropriate evidence-based and cost-effective prescribing and .de-prescribing where appropriate.

8.    Provide highly specialist medicines management support and training for GPs, nurses and other members of the multi-disciplinary care team for patients with multi-morbidity in all settings. 

9.  To support the Principal Pharmacist with development of protocols in collaboration with key stakeholders as necessary to support service delivery.

Service Development

1.   To work with the Principal Pharmacist for INT and other stakeholders to develop and refine service delivery models within the INT programme to support effective delivery of activity across all PCNs/ Neighbourhoods.  

2. To work closely with colleagues and other staff involved in the INT programme to promote and embed the role of the INT into local pathways of care. 

3. To provide operational and clinical support to developments around multi-morbidity and delivery of the INT model of care. 

4.   To support the planning and actions required to continuously improve the quality of service provided and ensure a quality improvement approach is taken to medication optimisation and any service development or re-design. 

5.  To contribute to and support the evaluation of outcome measures associated with the INT service 

Clinical Services & Patient Care

1.  To act as a clinical role model to other members of the wider MDT and provide direct supervision to non-clinical members within the core team in allocated Neighbourhood(s) to ensure improved outcomes achieved through the provision of holistic, team approach to care, which includes the safe and clinically cost-effective use of medicines.

2.  To provide clinical leadership on medicines optimisation in the context of multi-morbidity across the core INT and wider setting.  

3. To conduct patient facing and telephone consultations to independently review patients with complex multi-morbidity focusing on optimisation of cardiovascular disease management and improving long-term outcomes. 

4. To collaborate with multidisciplinary teams (MDTs) to develop and implement individualised care plans.

5.   To provide clinical advice and support to other members of the INT including complex scenarios to ensure a high standard of patient care delivered within the INT framework.

6.   To manage complex and non-routine medicines management problems in patients under the INT service, making onward referrals when needed. 

7. To demonstrate an intuitive grasp of situations based on knowledge, expertise and understanding and to make decisions about drug therapy with limited information. 

8. To work with colleagues to facilitate robust communication and onward referral pathways to support seamless care for patients managed by the INT service where complex medicines and/or other needs are identified. 

9.  To ensure efficient transfer of information related to complex medicines management needs across care interfaces and reconcile information received to ensure the safe transfer of care for vulnerable patients with complex medicines management needs.

10.   To work as an independent prescriber and review medication to ensure that patients medicines are optimised for safety, effectiveness and cost-efficiency in line with competency and agreed scope of practice as approved by the relevant Trust governance process.

Information & Data Management

1.  To contribute to the development of quantitative and qualitative performance measures, co-ordinate their use and be involved in disseminating, acting on and sharing learning from information gathered.

2.  To participate in the design and collection of clinical audit data, leading implementation in designated areas and participate in research projects to improve the quality of care and inform best practices. 

3. To utilise available information from audits, national guidelines, and benchmarking data to influence and implement improvement in service delivery. 

4.    To work closely with PCNs ensuring seamless integration of patient data for improved care co-ordination.

Staff Management and Education and Training

1.  To line manage one to two caseworkers and link workers/health coach within the INT providing supervision, guidance and support to ensure effective teamwork and delivery of goals. This will include matrix working with PCN clinical leads and business managers and leads to effectively manage and co-ordinate team members. This will include supporting appraisals, objective setting and sickness management.   

2.  To work with the Principal Pharmacist and other leads to identify and support the design and delivery of education and training around the INT service (including medicines optimisation in multi-morbidity and holistic, cost-effective prescribing), to colleagues, and more widely across the system when needed. Training delivery will range from small communications to formal presentations. 

3.    To  participate and contribute to clinical training programmes for trainee professionals across Lewisham where exposure to the INT model would aid learning and practice.

4.  To evaluate and ensure continuous development of own professional knowledge and competencies by attendance at in house/external training programmes, and appropriate self- education.

Financial

1.   To support and advise relevant leads and GP/primary care prescribers on delivering relevant QIPP, QoF and local targets in relation to medicines optimisation.

2.  To provide medicines advice regarding the use of cost-effective drugs across the primary and secondary care interface to the relevant stakeholders.

3.    To provide a value for money service to contribute to reduction of medicines related readmission of patients with complex medicines management needs by optimising medicines management and communication about medicines across care interfaces.

4.    To support the delivery of targets in the general practice setting in relation to medicines optimisation within the quality and outcomes framework and enhanced services in defined areas of multi-morbidity.

Research & Development

1.    To participate in clinical audit and research and development within the INT service and support publication of service results.

2.   To develop initiatives in the delivery of medicines optimisation within the INT model of care and contribute to development quality standards for clinical effectiveness.

3.   To develop working relationship and research links with academic units to promote collaboration in practice and research around medicines optimisation in multi-morbidity.

Communications and Relationships

1. To communicate clearly and sensitively about patient medicines management issues both internal and external to the Trust and in Primary Care Network setting. 

2.    To communicate and collaborate with the multidisciplinary healthcare team including doctors, nurses, pharmacists and social care professionals on a daily basis to address the complex needs of patients with multi-morbidity.

3.  To communicate complex and sensitive medication/ health care related issues to patients and relatives, including medication history taking, medication review and counselling and overcoming barriers to understanding and communication such as language, hearing, visual or cognitive difficulties.  Tact and persuasive skills are required when negotiating with patients to improve adherence with medication advice, with empathy and re-assurance necessary to address patient concerns. Communication may be either verbal in the form of face-to-face contact, over the telephone or in written form. 

4.  To work closely with other services within primary care to ensure patient referrals that support improved outcomes for patients are made with appropriate escalation where required.

5. To act as a link between primary and secondary care, facilitating smoother transitions for patients and promoting integrated care pathways.