Swydd-ddisgrifiad a phrif gyfrifoldebau manwl

The post holder is responsible for improving care for adult service users and carers, aged 
18 and over, across Medway Primary Care Networks. The nurse would work within the GP 
surgery facilities, providing the following support:  
  Support patients recently transferred back to the GP from Kent and Medway NHS 
and Social Care Partnership Trust (KMPT) Secondary Care ensuring patients with 
Serious Mental Illness (SMI), and Dementia, have the best possible chance to 
remain stable in the community.  
 To carry out annual reviews and physical health checks for mental health patients in 
primary care including but not limited to Dementia Annual Reviews, Serious Mental 
Illness (SMI) reviews.  
 Signpost patients to relevant community services in the community to support 
mental health recovery.  
 Work with local mental health services and the KMPT Primary Care Mental Health 
Service, maximizing effectiveness and avoiding duplication of care. 
 Attend community based multi-disciplinary team meetings aligned to their Primary 
Care Network when required.  
In addition to this, the nurse will also:  
 Work within and adhere to the relevant professional codes of conduct, standards 
of practice and relevant policies and guidelines.  
 As a health professional take responsibility for developing, planning, 
coordinating, delivering and evaluating the service provided to practices 
within the Medway area. The post holder will need to be flexible, 
innovative and proactive in-service development.  
 The post holder is an autonomous practitioner, responsible for provision 
of assessment, interventions, education, and discharge planning of 
clients referred from within the Medway area.  
 The post holder will act as a source of expertise and demonstrate 
advanced knowledge, skill and experience in the management of 
various mental health conditions, using a bio-psychosocial approach.  
 Liaises and supports other health care professionals, multi-agency 
professionals and third sector providers.  
 Required to report on the delivery of the programme against agreed 
targets.  
 To work as part of a team with other primary care nurses and the wider 
primary care workforce, in a variety of community settings where there 
is a requirement to make decisions within local policies and guidelines.  
Key dimensions of the role include: 
 Support recovery by pro-actively enabling medically-stable individuals to 
move from secondary to primary care. Support must be personalised to 
patient (and their family/carers) needs and that agreed shared care 
responsibilities are in place and are clearly documented. This will 
include proactively identifying and booking patients in for appointments.  
 Provide support to primary care clinicians and practice staff in the 
management of mental health conditions in primary care. Support the 
effective ‘navigation’ of patients through the various mental health 
systems and services. Ensure that local voluntary sector, health and 
social care provision are used effectively.  
 Liaise with GPs to improve the physical health outcomes of those with a 
long-term mental health condition and the mental health outcomes of 
those with a long-term physical health condition.