CHE: Clinical Nurse Specialist Gerontology

**Please ensure you download, save and read the Job Specification. **

Location of the Post:

There is currently one permanent, whole-time vacancy available in Community Healthcare East based in Clonskeagh.

A panel may be formed as a result of this campaign for Community Healthcare East, Clinical Nurse Specialist (CNSp.) (Gerontology – Integrated Care) from which current and future, permanent and specified purpose vacancies of full or part-time duration may be filled.

Details of the Service:

A significant programme of reform is underway in Services for Older Persons and Chronic Disease supported by the strategic direction set out under Slaintecare (2017), the Enhanced Community Care (ECC) business case (2019), HSE Corporate Plan (2020), National Service Plan (2021) and the National Clinical Programmes.

The Enhanced Community Care Reform Programme (ECC) is focused on the transformation of community care with an emphasis on establishing Community Health Networks and Specialist Community Teams working within Ambulatory Community Hubs. These plans and organise services for a defined population, enable integrated care to be implemented, shifting the focus away from acute hospitals towards a new model of specialist care in the community. The redesign of services allows new pathways to be developed between hospitals, community services, primary care, health & wellbeing and voluntary sectors to develop new networks of care for Older People and people with Chronic Disease.

The investment in an Enhanced Community Care Model will be delivered on a phased basis, with a view to national coverage being achieved within a 2–3-year period. Three priority areas have been identified as follows:

· Structural reform with Community Health Networks (CHNs) becoming the basic building blocks for the organisation, management, and delivery of community services across the country.

· Creating specialist ambulatory care hubs within the community for the management of chronic disease and older people with complex needs.

· Scaling Integrated Care for older people and chronic disease through the recruitment of specialist integrated care teams across the care pathway including Frailty at the Front Door Teams.

The ECC Model is underpinned by a set of key principles including:

· Eighty percent of services delivered in Primary Care are through the Community Networks.

· Identifying and building health needs assessment at a Network level (approximate population of 50,000) based population stratification approach to identify people with complex, longitudinal care needs with chronic disease who are high need service users, thereby ensuring the right people benefit from care pathways that deliver care closer to home, based on the complexity of their health care needs.

· Utilisation of a whole system approach to integrating care based on person centred community models, while promoting self-care in the community.

· Learning from and delivering services based on best practice models in the community and the extensive work of the integrated care clinical programmes particularly in Older Persons and Chronic Disease services.

· Availability of a timely response to early presentations of identified conditions and the ability to manage appropriate levels of complexity related to same.

· Resources applied intensively in a targeted manner to a defined population, implementing best practice models of care to demonstrate the delivery of specific outcomes and sustainable services.

· The need to frontload investment, coupled with reform to strengthen community services.

· Embed a preventative approach into all services.

The Integrated Older Persons/Chronic Disease Service Model sets out the end-to-end service architecture for the identification and management of people living with chronic disease and frail older adults with complex care needs. The focus is on providing an end-to end pathway that will reduce admissions to acute hospitals by providing access to diagnostics and specialist services in the ambulatory care hubs in a timely manner. For patients who require hospital admission, the emphasis is on minimising the hospital length of stay, with the provision of post-discharge follow up and support for people in the community and in their own homes, where required. A shared local governance structure across the local acute hospitals and the associated CHO will ensure the development of a fully integrated service and end-to-end pathway.

The integrated older persons service is a specialist multidisciplinary service primarily targeting and managing the complex care needs of the older person with multiple co-morbidities across a continuum of care. The overall aims of the service are to:

· Provide a specialist geriatric opinion using a multidisciplinary approach to support older people with complex care needs.

· Develop a person-centred care planning approach that supports robust and timely communication across care settings.

· Support appropriate and timely reduction of Emergency Department (ED) attendance through the development of care pathways that support GPs and others in assessment of older with escalating care needs.

· Provide support and education to the older person, carers and healthcare professionals.

The Clinical Nurse Specialist (Outreach) will work closely with the integrated care consultant geriatrician and Integrated Care Team for Older people (ICTOP) to implement care pathways that supports the needs of older people in Residential Care Facilities (Public & Private). The role will work across acute hospital and RCFs with an outreach/ inreach function.

Purpose of the Post:

Clinical Nurse Specialist (Outreach)post is part of a broader integrated care team were RCF outreach is supported. The CNSp will contribute to the improvement of the health care experience and outcomes of older people who are resident in RCFs.

The CNSp. Liaison service will provide a point of contact for advice, guidance and support for individual residents requiring additional clinical expertise. This role will facilitate rapid access to specialist advice and aims to build confidence within the residential care facility and within the acute hospital to maximise its ability to provide care in that setting. The role will function as part of a network of services supporting care of older people in RCFs, many of whom have complex needs that require specialist gerontological expertise (COVID-19 Nursing Homes Expert Panel: Final Report (2020).

The Clinical Nurse Specialist (Outreach) will deliver care in line with the five core concepts of the role set out in the Framework for the Establishment of Clinical Nurse Specialist Post, 4th edition, National Council for the Professional Development of Nursing and Midwifery (NCNM) 2008.

Caseload

The Clinical Nurse Specialist (Outreach) caseload comprises of older people living with frailty and with complex care needs where place of care is in a RCFs (Public/Private)

The objectives of the post are to:

· Provide specialist gerontological nursing expertise for RCFs within the acute hospital catchment area.

· Be the point of contact and liaison with RCFs, GPs, Older Persons’ Services, Frailty Intervention Teams, Community Intervention Teams, and Outpatient’s antibiotic Therapy (OPAT) where appropriate in advising on the care of referred residents within the defined care pathway under the integrated care team.

· Enable continued delivery of care to avoid escalation to acute hospital to facilitate AMAU and day hospital attendance where appropriate.

· Co-ordinate the management and flow of information regarding residents admitted/discharges from acute/RCF’s liaising directly with care providers/DONs.

· Co-ordinate investigations and referral pathways in/out of the acute hospital through locally agreed processes.

· Provide clinical leadership to empower, educate and enable RCF staff as well as family/carers in the provision of person-centred safe quality care.