Description
We are looking for a Registered Nursing Associate (RNA) to join the Haringey Multi-Agency Care and Coordination Team (MACCT) who is passionate about integrated community care and supporting frail and complex patients.
You will work closely with GPs, Physiotherapists, Social Workers, Pharmacists, Occupational Therapists, Community Matrons, Trusted Assessors, Mental Health Practitioners, Dementia Navigators, and the administrative team.
In this role you will undertake activities beyond traditional RNA duties, adopting shared competencies across the multidisciplinary team (MDT) in line with the Multi-Agency Care and Coordination Team (MACCT) model.
You will be supported to develop advanced skills in frailty, proactive case finding, pressure ulcer care and medication management where needed, continence and holistic assessment.
Main duties of the job
You will work as a core member of the Multi-Agency Care and Coordination Team (MACCT), delivering proactive, holistic, person-centred care for adults (18+) in Haringey who are living with frailty, complex needs, or are at high risk of unplanned hospital admission.
You will undertake delegated and competency-based tasks from:
- Community Matrons (CM)
- Associate Community Matrons (ACM)
- Occupational Therapists (OT)
- Physiotherapists (PT)
- Social Worker (SW)
- Pharmacists
- Other MDT clinicians
You will be allocated a caseload by the Community Matron/Associate Community Matron undertaking holistic assessments, planning and prioritising workload, implementing evidence-based interventions, and evaluating outcomes.
Following successful completion of the frailty induction process, you will:
- Undertake frailty assessments and coordinate care
- Present patients at multi-disciplinary meetings (MDT)
- Initiate referrals within competence
- Escalate emerging risks promptly
Job responsibilities
- Undertake follow-up assessments for patients previously reviewed by senior clinicians.
- Complete actions identified during Comprehensive Geriatric Assessment, initiating internal/external referrals within competencies.
- Undertake frailty assessments following frailty induction and competence signed off by supervisor.
- Present patients at MDT meetings and act as a care coordinator, when deemed appropriate.
- Escalate changes, emerging risks, or concerns promptly.
- Manage an allocated caseload independently within competence.
- Reassess patients holistically and escalate concerns via internal pathways.
- Work collaboratively with GPs, Physiotherapists, Social Workers, Pharmacists, Occupational Therapists, Community Matrons, Trusted Assessors, Mental Health Practitioners, Dementia Navigators, and the administrative team.
- Act in the best interests of patients and service users to promote and prevent ill health and contribute to their integrated care.
- Monitor the condition and health needs of patients and service users on a continual basis in partnership with colleagues, families, and carers, referring to others for reassessment, when required.
- Actively contribute to an effective learning environment and support others in their learning.
- Recognise and adhere to the Nursing and Midwifery Code of Conduct for Nurses, Midwives, and Nursing Associates and work within their scope of practice following the professional standards of practice and behaviours for nurses, midwives, and nursing associates and the standards of proficiency.