Job Description Job Title: Advance Care Planning Specialist Nurse Job Purpose Saint Michaels Hospice is delighted to launch a new.....
Job Description Job Title: Advance Care Planning Specialist Nurse Job Purpose Saint Michaels Hospice is delighted to launch a new person-centered advance care planning (ACP) service for people who have been identified as having a palliative diagnosis. The Advance Care Planning Nurse Specialist is a new role which through working as part of a Clinical Team will increase the quality and experience of care provided for patients with a palliative diagnosis and their families through the provision of integrated care and reducing inequalities. Key Tasks Key Tasks Operational: Provide support and expert advice whilst undertaking sensitive discussions with patients & relevant family members to prepare an advance care plan. This will include patients with capacity to make decisions about their future care and for those without capacity (following a documented mental capacity assessment), best interests care planning about their future care will be made by involving their next of kin, relevant family/carers or appointed attorney for health and welfare. Discussions will include supporting patients with choosing their preferred place to die as far as is reasonably possible. Work as an autonomous practitioner using evidence-based knowledge, clinical reasoning, critical thinking and reflection to support a caseload of patients with varying levels of palliative care needs. Provide a quality service to those identified as having a palliative diagnosis whilst working closely with those who refer into the service such as; GPs, Specialist Palliative Care Team, Specialist Nurses, acute hospital settings, care homes and internal Hospice referrals. To understand clinical conditions and potential problems patients may experience with a palliative diagnosis and develop advance care plans to meet these anticipated physical needs whilst also considering their holistic, psychological, spiritual, social & cultural needs. This will include people with multiple morbidities and comorbidities including frailty, dementia, and other long-term conditions. To triage all incoming referrals inline with NYHC procedures, ensuring they are dealt with in a timely manner. Sensitively communicate difficult information with patients and their families, recognising the impact of death, dying and bereavement and that their priorities and ability to communicate their wishes may vary over time. Ensure that families, carers, and others identified as important to the person are supported and their needs are explored, respected, and met as far as possible and that they are signposted where needed. To complete advance care planning documents most appropriate to the patients needs & wishes. This may include advance care plans including advance statements, treatment escalation plans which may include ReSPECT documents and emergency health care plans. Work in partnership with patients who have capacity to support their completion of an advance decision to refuse treatment where this is appropriate and desirable by the patient. Demonstrate competency with DNACPR decision discussions with patient/families and complete the required documentation, supported by the Medical Team. Communicate effectively, including management of any disagreement with the multi professional team, other services/agencies and apply principles, guidance and laws regarding ethics and confidentiality. Provide advice and support as required to staff in the wider team. Record, with the patients consent, the advance care plan onto the Harrogate Future Care Planning Template, which is part of SystmOne, in a timely manner. Support and provide high quality palliative and end of life care for patients and families by facilitating referrals to other services both internally and externally to the Hospice. Ensure a timely response to referrals and contacts from patients/families to the service which meet the service specification. Plan, prioritise and organise own workload. Work in collaboration with acute, primary care and community teams in the management of patients. Provide mentorship and teaching to students and new members of the team delivering a positive learning environment. Provide training to new service members, clinical teams within the hospice and volunteers to promote service sustainability and effectiveness. Help maintain a pleasant and safe environment for patients, volunteers, visitors, and staff. Strategic Contribute to the delivery of the North Yorkshire Hospice Strategy Financial Manage the hospice resources effectively working closely with the leadership team to support service delivery and innovation. Regulatory Maintain accurate electronic patient records in line with NMC Record Keeping guidelines. Actively keep up to date by participating in educational opportunities, applying evidence-based practice and ensuring the requirements of revalidation and CPD are met. Management Escalate any clinical, service, or safeguarding concerns in line with the hospice policies and protocols. Initiate and participate in audit and evaluation of the service in the interests of providing quality care, cost effectiveness and to identify opportunities for service improvement in collaboration with the senior leadership team. Contribute to data collection to demonstrate the service is meeting its service specification contract requirements. Contribute to preparation of reports for presentation to the HELPSS project board. On request, with support, to work across the organisations services to support our patients in all locations. Receive clinical supervision regularly. Logistics Provide the service in the most appropriate way to meet the patients and family needs. This will include face to face in the home, care home, hospice or clinic setting, virtually or by telephone. The above is not an exhaustive list of duties and you will be expected to perform different tasks as necessitated by your changing role within the organisation and the overall business objectives of the organisation. Key results/objectives/measures of success For all patients referred to the service to be offered an appointment to complete their advance care plan within 4 weeks of referral. For all patients referred to the service to be offered an appointment to complete their advance care plan within 4 weeks of referral. To Increase the quality and experience of care provided for patients with a palliative diagnosis. To assist the service in meeting the objective of reducing Harrogate District Foundation Trusts unplanned acute hospital bed days for patients in the last year of life. Overarching responsibilities To embed the values of the organisation into your working practices evidencing this regularly and ensuring this remains a priority. To live out our values, which drive all that we do, in the context of your everyday work following our behaviour framework. To work in accordance, and fully comply, with our organisational policies and procedures. To carry out all duties in accordance with the law, regulations, organisational frameworks, recognised professional guidelines and the have a commitment to FREDIE, integration and collective decision making. Throughout your time with us we will conduct ongoing employment checks and performance reviews relevant to your role, for example professional registration checks, DBS, appraisals, and regular contact meetings.
