Compass Health team Compass Health Management staff Primary Health Care Providers Local Community Groups Māori Health Team

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1 Position Title: Primary Function: Reports To: Outreach Nurse The Outreach Nurse will work holistically with the client and family/whānau, in partnership with General Practice Teams and secondary care specialists, to help them manage their conditions, ensure that the support and services they require are put in place and delivered in an integrated manner, and link them into selfmanagement programmes. Integrated care: Involves treating the whole person, assisting the innate healing properties of each person, and promoting health and wellness as well as the prevention of disease Employs an interdisciplinary team approach guided by consensus building, mutual respect, and a shared vision of health care that permits each practitioner and the client to contribute their particular knowledge and skills within the context of a shared, synergistically charged plan of care Involves primary and specialist (secondary) service health professionals working together, and with a range of other family and community support networks, in a unified way, to deliver the best possible programmes across the health continuum. To achieve this, the Compass Health Outreach Nurse, will: Utilise a Whānau Ora approach when undertaking Health Assessment and Care Planning processes, in partnership with client/family/whānau and relevant health care providers Provide integrated, structured client care within a comprehensive, case management framework Provide individual and group self-management, and self-management support Contribute to the development of capability of General Practice Teams, peers and colleagues Contribute to the implementation of collaborative clinical pathways for people with long terms conditions Work in partnership with the Director of Māori Health and the Māori Health team to identify objectives relevant to this role that will contribute to strengthening Māori Health outcomes Clinical Services Manager Functional Relationships: Compass Health team Compass Health Management staff Primary Health Care Providers Local Community Groups Māori Health Team Primary Location: Hours: The position will be based at the Compass Health Kapiti office; however as an outreach role, a large part of the role will be delivered in the community 20 Hours per week Nature of position: Permanent part time position Outreach Nurse-Kapiti JD March

2 Background: Compass Health is a not-for-profit Trust registered with the Charities Commission and governed by a Board consisting of 11 Trustees. Compass Health provides quality primary health care services to an enrolled population of 286,669 people across the Wellington, Porirua, Wairarapa and Kapiti areas. We work in two health alliances: with Wairarapa DHB; and with Well Health, Cosine, Ora Toa and CCDHB. We employ almost 100 people and contract with 59 medical practices. We also provide corporate services to Central PHO and a number of general practices. As an organisation and as individuals we value: Trust: Respect: Unity: Accountability: Courage: Maintaining open and honest relationships Embracing diversity, uniqueness and ideas Valuing strengths and skills Working in a transparent and responsible manner Participating with confidence and enjoyment Key Responsibility Activities Management of Nursing Care the presentation, progression, path physiology and prognosis of common long term conditions to client care therapeutic interventions, including relevant pharmacology and medicines management to client care Demonstrates an awareness of the wider determinants of health and the impact that these have on wellness and peoples situations Undertake a comprehensive health assessment in partnership with client/family/whānau and relevant health care providers Develop and document a comprehensive plan of care in partnership with client/family/whānau and relevant health care providers Provide evidence based nursing care to people with long term conditions within the overall philosophy of enabling and promoting independence, dignity and choice Implement effective community-based primary prevention, secondary prevention and rehabilitation strategies that will decrease the risk factors of those experiencing long term conditions Work with people with long term conditions and their families/whānau in planning for the future and supporting access to resources for making choices about end of life care (if applicable) Able to recognize deterioration in wellbeing, referring to an appropriate service, coordinating and supporting the delivery of the appropriate care Plan and implement transfer of care and/or discharge of the person with a long term All clients have a standardised Assessment and Care Plan Evidence of client consent Evidence of copy of the plan given to the client Evidence of collaboration with providers in the development of assessment and care plan Evidence of review and evaluation of assessment and care pans within agreed timeframes Each consultation is fully documented in a client record Audits of assessment and care plan completed and recommendations actioned All referrals are actioned appropriately and in accordance with the Ministry of Health and NZ Guidelines Group s document Evidence Based Best Practice (link on: Outreach Nurse-Kapiti JD March

3 condition as per agreed protocols Aware of cross cultural communication strategies, and apply these understandings in order to enhance therapeutic and professional relationships Ensure that the service identifies and addresses issues of equity and access for people with long term conditions Provide Care Coordination for Moderate-Complex clients through Case Management Work with General Practice Teams (GPTs) to identify and confirm the health and wellbeing needs of clients through Practice Profile/Disease Registers and referrals from healthcare providers Actively support the GPT to analyse and interpret data in defined chronic condition populations Ensure processes established with other providers for identifying those people with moderately complex long term conditions, to assess, plan and coordinate their care and ability to manage inter-professional and interagency working Coordinate and organise plans of care for complex clients, ensuring an integrated approach to service delivery Monitor the care provided for clients with long term conditions, which may result in hospital admission and readmission Apply in-depth knowledge of relevant legal and ethical issues related to caring for people with long term conditions Recognize the impact of socio-economic and personal circumstances on people with long term conditions and advise on relevant support services Applies Case Management Processes for clients with specific complex chronic care needs Record keeping to promote effective communication and engagement Clients are seen according to PHO entry/exit criteria Demonstrates knowledge of client complaints process and Client Code of Rights Support Self Care, Self-Management and Enabling Independence in partnership with the client, family/whānau and interdisciplinary team members Promote effective client self-management and self-management support (individual and group) to address specific health and wellbeing needs Taking into account readiness to change, selfefficacy and advocacy, support the client/family/whānau with collaborative problem definition Target the issues that are of the greatest importance to the client/family/whānau, help set realistic goals, and develop a personalised plan of care Working knowledge of CCM model and its role in improving services Evidence of linking with PHO self-management groups Evidence of collaborative working Auditing of client satisfaction survey Application of cultural principles Incorporate motivational interviewing techniques into self-management support Provide active and sustained follow up at regular Outreach Nurse-Kapiti JD March

4 intervals to ensure improved health outcome Work with awareness of cultural responsiveness to others Incorporate Whānau Ora principles into care delivery when and where appropriate Professional Practice and Leadership Act as a role model and a resource person for other nurses and health practitioners Work in a consultative/collaborative manner within the team Demonstrate clinical leadership, taking responsibility for the continuing development of self and others through: o personal and professional development o appraisal, supervision and support o professional accountability o reflective practice o team working and development o educational programmes, coaching o communication skills within the team and other services/agencies Provide professional peer support to other team members Evidence of engagement with professional organisations Completion of Performance Appraisal annually Completion of annual Professional Development Plan Demonstrate understanding of the issues relating to personal and professional competence Demonstrate understanding of current policy, strategy and guidelines related to long term conditions Assist in the development of relevant clinical policies and procedures Interagency and Partnership Working collaborative and interagency working Work across organisation and professional boundaries to enable personalised care to be delivered Evidence of exchange of information between primary health care providers and other members of the multidisciplinary team Annual review monitoring for clients is completed (where applicable) Contribute to the review of the current system and assist in the development of any future systems to improve care received by clients. Referrals are stored in the Patient Management System (PMS) at Compass Health and/or the practice Support primary health care providers to ensure that referrals to other health practitioners and services are effective and timely Maintain liaison with primary health care providers by developing systems to ensure outcome/letters are sent to GPT s and other Health Professionals as appropriate In-depth knowledge and understanding of the PHO performance programme Utilise conflict and dispute management skills if required Outreach Nurse-Kapiti JD March

5 Service Development & Quality Improvement Aware of Service and Quality improvement tools and processes Demonstrate understanding organisational development and change management Contribute to service development initiatives to people with long term conditions in multiple settings with multiple stakeholders, as agreed with the Line Manager Clinical audits completed as appropriate Improvements implemented from client and provider satisfaction surveys or audits Aware of contracts as relevant to role Structured approach to Service and Quality improvement evident Accurate completion of SEM forms Develop and implement quality improvement activities appropriate to the service Participate in the development and implementation of standardised, best practicebased systems and processes. Skilled in managing clinical events, including risk assessment and appropriate management of risk Act as an agent of change for the improvement of service delivery Awareness of effective significant event management (SEM) Improve Health Outcomes of Maori Engage and further develop relationships with Iwi/Māori Monitor Maori patient referrals to Outreach Service Build an effective culturally competent and responsive workforce Actively work with General Practice teams to support their Maori population Ensure that the cultural requisites of staff are met through the organisation s structures, policies and processes Ensure the workforce reflects the diverse nature of our community Attend Maori Cultural training sessions Relevant actions of Ka Po,Ka Ao, Ka Awatea are met and delivered Support sustainable organisational commitment to Whānau Ora and Ka Pō, Ka Ao, Ka Awatea Health and Safety Ensure that work is done in a safe environment Report and work to eliminate, isolate or minimise any hazards Participate in health and safety management practices for all employees The organisation complies with its responsibilities under the Health and Safety in Employment Act 1992 and any subsequent amendments or replacements legislation Apply the organisation s health and safety policies and procedures PERSON SPECIFICATION: Essential skills, knowledge and experience Qualifications Passionate about providing health that meets the needs of the community Registered General and Obstetrics Nurse (RGON), or Outreach Nurse-Kapiti JD March

6 Experience in the care and management of chronic morbidity and co-morbidity especially diabetes, respiratory and cardiovascular within primary care Registered Comprehensive Nurse (RCOMP) Experience in health education and health promotion Demonstrated ability to build and maintain sound working relationships with general practice teams Well-developed interpersonal and communication skills with ability to work with a wide range of people in a variety of settings Innovative and pragmatic when problem solving Outcome focused and able to prioritise and set goals Understand the relevance and impact of culturally appropriate service provision and how culture influences behaviour both internal and external to the organisation Experience of developing and implementing culturally responsive strategies across all levels of the organisation Experience of working with diverse populations Computer literate Full Driver License EMPLOYEE ACCEPTANCE: This Position Description has been agreed between: Management Representative (print then sign) and Employee (print then sign) Date: / / Outreach Nurse-Kapiti JD March