National HIV Nurses Association

Understands concept of working across a managed service network and has awareness of the relevant specialist policy documents [1]

Understands role of the MDT and own role within it

Understands link between health and social care and the need to provide integrated care

Identifies key HIV specialist personnel across network in relation to own area of work

Contacts appropriate HIV specialist personnel for advice and information about clinical issues

Ensures patient access to the relevant members of the MDT

Aware of the national standards on integrated health and social care in HIV [2]

Utilises referral pathways for inpatient and outpatient care in line with local care pathways

Participates in MDT meetings and discussions of patient care

Acts as an advocate for the patient as required

Develops key working relationships across network with peers and key network personnel

Coordinates MDT working and facilitates MDTs and case conferences etc

Attends network or subgroup meetings to participate in identifying nursing pathways across sectors

Ensures discharge plans are based on the integration of health and social care according to patient need

Monitors referral pathways in practice and liaises directly with network leaders when care pathways are not seamless

Identifies those patients with increased needs who would benefit from joint care coordination and refers patients appropriately to the MDT and across services within the network

Identifies nursing referral pathways across network for all aspects of HIV care provision

Leads and participates in the cultural changes required for successful integration of health and social care

Designs systems for patient access to network services

Assists in the development of integrated arrangements for health and social care; for example, single points of access for health and social care, single health and social care assessments

Works with nursing leaders across network and PCT to refine provision of shared services

Develops consistent nursing policies and standards across the network, including infection control and puts systems in place to audit and monitor these

Participates in network steering group at a senior nursing level and informs sector-wide commissioning of nursing and other clinical services

Understands the issues around confidentiality affecting people with HIV and is able to apply this to practice across a number of clinical settings

Recognises the impact of HIV/AIDS stigma on the patient experience of living with HIV

Identifies when patent disclosure of HIV diagnosis can be difficult and engages the MDT to assist patients with disclosure issues

Recognises difficulty in disclosing HIV diagnosis after death and acts as a patient advocate when this arises

Actively promotes appropriate practice with regard to confidentiality

Able to proactively support patients where stigma has an impact on their health and well-being

Assists patients with disclosure of diagnosis where required

Ensures that the patient's wishes on disclosure of diagnosis after death are known to the MDT and that the patient's wishes are respected where possible

Establishes systems and guidelines to appropriately protect confidentiality across HIV services

Works with the MDT across statutory and non-statutory services to tackle stigma and discrimination across the service network

Works with the wider MDT to develop robust systems to protect confidentiality after death