Care Manager job description

• Job Title: Nurse/Allied Health Professional (Care Manager)
• Band: Band 6 Agenda for Change Terms and Conditions
• Accountable to: Clinical Team Leader, Birmingham Own Health (BOH)

Span of Authority

Financial Responsibility
Budget holder: No
Budget amount: Not Applicable

Role summary

• To promote wellness, improved outcomes and self care within a defined population of members with a long term condition(s) and complex health needs and support their appropriate utilisation of health services.
• To work with the individual member and providers of care to develop and implement individual health plans and provide support to the member in self management. Member is defined as a patient with one or a number of long term conditions that are referred into the programme by their GP.
• To undertake member enrolment and initial assessment, the planning, implementation, coordination and review of health plans and encourage the appropriate utilisation of services to meet at risk members complex health needs. This will be achieved through proactive telephone communication using health behaviour change coaching, facilitated by decision support software and the co-ordination of available healthcare resources.
• Care management will take place within the philosophy of enabling and promoting self care, self management and independence.
• The post holder will be responsible for the supervision, coaching, teaching, precepting and mentoring of associate care managers, health coaches and other staff and/or students.

The job description is underpinned by the competency framework and is not intended to be an exhaustive list of tasks.

Main duties and responsibilities

1. Proactively managing long term conditions

1.1 Plan and conduct telephone consultations with members to assess and monitor needs, plan care, review effectiveness of services and support self-management.

1.1 Synthesise member information and clinical knowledge to plan, implement, monitor and review individualised health plans and make appropriate interventions to attain agreed goals and reduce risk of deterioration/exacerbation.

1.2 Work collaboratively with member, members of the family and caregivers, General Practitioner, hospital and other health services to develop and implement a health plan using the 8 care management priority framework.

1.3 Oversee and approve the development of care plans by non-qualified colleagues and act as mentor offering clinical guidance and intervention when appropriate.

1.4 Accept referrals from other team members, of complex cases and those requiring a high level of nursing experience and/or knowledge.

2. Managing information

2.1 Maintain timely and appropriate data collection using OwnHealth software.

2.2 Complete assessment and monitoring of the member utilising approved tools and procedures.

3. Supporting self care, self management and enabling independence

3.1 Provide education and coaching to members and caregivers on disease processes, disease management and health promotion to enable them to make informed decisions regarding self-care and maintain wellness.

3.2 Engage and coach the member around the health plan and health behaviour change to motivate and empower the member to achieve agreed goals.

4. Leading care co-ordination

4.1 Liaise with local service providers to arrange and coordinate services across the continuum of care.

4.2 Using advanced communication and interpersonal skills act as liaison with providers, members, family members, health services, community sources and health plan.

4.3 Maintain an appropriate level of contact with other service providers and share information in an appropriate and timely manner.

5. Professional effectiveness

5.1 Work in collaboration with other health practitioners to ensure optimal results and strengthen their relationship with the member.

5.2 To act as a clinical resource for staff and to actively participate in clinical supervision to facilitate personal and professional development.

5.3 To share and utilise areas of specialist practice with peers and colleagues to inform and enhance patient care.

5.4 Support and mentor other team colleagues providing clinical guidance and support to non-qualified members of the team

5.5 Support teamwork and display professionalism during daily job responsibilities. Participate actively in team meetings.

5.6 Communicate with the Service Delivery Manager with complex, problematic cases and operational issues and seek appropriate support.

5.7 Maintain and comply with NHS Direct and project policies and procedures.

5.8 Maintain a high level of professionalism in manner and communication.

5.9 Maintenance and development of current knowledge of clinical area, pharmacology, member interaction skills, coaching for health behaviour change, health care ethics and legal aspects of care management.

5.10 Undertake audit and supervision as stipulated, participate in performance management, self-assessment and maintain a personal development plan/CPD portfolio.

5.11 To adhere to and implement national and local policies and procedures and work within the NMC Code of Professional Conduct.

General information

The postholder must at all times carry out his/her responsibilities with due regard to the NHSD policies and procedures in particular IWL, Equal Opportunities, Health & Safety, Confidentiality and Data protection Act.

All staff have a responsibility to participate in the NHSD Appraisal Scheme and to contribute to their own development, and the development of any staff they appraise or are responsible for.
The above Job Description is not intended to be exhaustive, the duties and responsibilities may therefore vary over time according to the changing needs of the service.

Confidentiality

In the course of your employment you will have access to confidential information relating to NHSD business. You are required to exercise due consideration in the way you use such information and should not act in any way, which might be prejudicial to the NHSD interests. Information which may be included in the category which requires extra consideration covers both access and to the general business of the NHSD and information regarding individuals. If you are in any doubt regarding the use of information in the pursuit of your duties you should seek advice from your manager before communicating such information to any third party.

Data protection

NHSD is registered under the Data Protection Act 1998. You must not at any time use the personal data held by NHSD for a purpose not described in the Register entry or disclose such data to a third party. If you are in any doubt regarding what you should or should not do in connection with the Data Protection Act then you must contact the Director of ICT.

Health and safety

Employees must be aware of the responsibility placed on them under the Health and Safety at Work Act (1974) to maintain a healthy and safe working environment for both staff and visitors. Employees also have a duty to observe obligation under the NHSD and departmental Health and Safety policies, and to maintain awareness of safe practices and assessment of risk.

Financial regulation

All staff are responsible for security of the property of the NHSD, avoiding loss or damage of property, and being economical and efficient in the use of resources. Staff should conform with the requirements of the Standing Orders, Standing Financial Instructions and other financial procedures including the Code of Conduct and Accountability and the Fraud and Corruption Policy.