Housebound Nurse

This role will provide proactive reviews for registered housebound patients in alignment with the Quality and Outcomes Framework (QOF) targets.

This includes proactive, high-quality care management to meet both individual patient needs and PCN-wide QOF indicators.

To assess, devise, and evaluate care plans for housebound patients, ensuring that their unique health needs are met in alignment with PCN and QOF care goals.

Engage with patients, families, and caregivers to promote a patient-centred approach and ensure care aligns with both patient preferences and QOF targets.

Identify patients suitable for pro-active care via the Frailty and integrated care team MDTs and remote monitoring programme. Referring as appropriate.

Conduct long-term condition reviews, including diabetes, cancer, learning disabilities, dementia, mental health, and blood pressure management, to support QOF performance and outcomes. Working in collaboration with practices/clinicians.

Deliver specialist care in line with your scope of practice.

Use prescriptive authority (where qualified) to enhance medication management, especially in managing long-term conditions, with attention to QOF outcomes.

Provide patient and family education on managing health conditions, preventive care strategies, and self-management aligned with QOF indicators.

Act as a clinical role model, delivering evidence-based care and contributing to the professional development of team members.

Mentor supporting roles to achieve relevant patient outcomes.

Oversee planning and co-ordination to support effective service delivery.

Participate in clinical audits and research projects, implementing improvements based on findings to enhance patient care protocols.

Contribute to the development and revision of PCN guidelines, protocols, and procedures, ensuring adherence to national and local standards, including QOF requirements.

Actively engage in PCN quality improvement initiatives aimed at enhancing patient identification, assessment, and long-term support aligned with QOF.

5. Strategic and Collaborative Work

Work proactively with PMs and directors to develop integrated care pathways, contributing to a holistic model of care.

Advise on policy development and contribute to the PCNs strategic work streams.

Farnham Primary Care Network brings together GP practices and healthcare professionals to provide high-quality, patient-centred care to over 50,000 patients across the Farnham area.

We are committed to innovation, collaboration and continuous improvement, creating an environment where staff feel supported, valued and empowered to develop their careers.

Qualifications

Desirable: - Prescribing qualification is preferred, ideally Independent/Supplementary Prescriber status.

Experience