Advanced Nurse Practitioner (Frailty and Proactive Care)

The post holder will work across Bradford City PCN4 practices and within community settings to identify, assess and manage patients with moderate to severe frailty, helping them remain independent and avoid unnecessary hospital admissions.

The role will focus on proactive care, comprehensive geriatric assessment, anticipatory care planning, multidisciplinary team working and patients with declining health.

The post holder will work autonomously within their scope of practice, undertaking advanced clinical assessments, diagnosis, treatment and prescribing where appropriate.

Undertake advanced clinical assessment of

patients with frailty, complex needs and multiple long-term conditions

Provide holistic assessment including physical,

psychological, functional and social needs

(CGA)

Diagnose and manage acute and chronic

conditions within professional competence

Independently prescribe medication where

qualified and appropriate

Develop personalised care and support plans

Complete anticipatory care planning and advance

care planning discussions

Undertake home visits for housebound and

vulnerable patients

Support care home residents through regular

clinical reviews

Identify patients at risk of deterioration,

admission or crisis and implement preventative interventions

Participate in multidisciplinary case

management meetings

Lead the identification of patients living with

moderate and severe frailty using risk stratification tools and clinical

judgement

Support delivery of PCN proactive care and

personalised care programmes

Develop pathways for frailty management and

prevention

Support falls prevention initiatives and

medication reviews

Coordinate care for patients with complex needs

and frequent hospital admissions

Work collaboratively with community services to

reduce avoidable admissions and improve patient outcomes

Promote healthy ageing and independence

Provide clinical leadership for integrated

services across the PCN

Support service redesign and quality

improvement initiatives

Participate in audit, evaluation and service

development projects

Support implementation of local and national

priorities relating to frailty

Contribute to workforce development and

training of other healthcare professionals

Work collaboratively with GPs, Clinical

Pharmacists, Social Prescribers, Care Coordinators, Community Nurses,

Attend multidisciplinary team meetings and

neighbourhood team meetings

Develop effective relationships with secondary

care, community providers, voluntary sector organisations and care homes

Support integrated working across

organisational boundaries

Maintain accurate and contemporaneous clinical

records

Work within NMC Code, professional standards

and local policies

Participate in clinical audit and quality

improvement activity

Maintain mandatory training and continuing

professional development

Support safeguarding processes for adults at

risk

Contribute to incident reporting and learning.

City Primary Care Network 4 (PCN4) is a network of Bradford City Practices

working collaboratively across the network area to look after the health of our

local population. The PCN which comprises of 5 local Practices with a total

population of around 48,000 registered patients.

Knowledge and Skills

Experience

Qualifications

Desirable: - Qualification in Frailty, Gerontology or Older Persons Care; - Leadership or management qualification

Personal Attributes