Long Term Conditions Nurse / ACP

Main duties

of the job

Direct clinical involvement in long term

condition/chronic disease management

Delivery of nursing care to patients in the

practice population

Providing advice, support and liaison with other

practice staff

Job

description

Enable individuals with long term conditions and their carers to make

informed choices concerning their health and well being and to organise their

own support, assistance and action and promoting self care

Support individuals with long term conditions and their carers to change

their behaviour and to reduce the risk of complications

Manage programmes of care for patients with acute and chronic disease by

planning and evaluating care

Work across boundaries and in partnership with primary and secondary care

clinicians and social services, coordinating care promoting a

multi-disciplinary approach.

Review prescribed medication and provide advice on all aspects of

medicines management, within scope of practice. Refer to relevant clinicians

where appropriate.

ConfidentialityThe post holder will maintain

appropriate confidentiality of information relating to commercially sensitive

matters regarding PCN business, and to personal information relating to members

of staff and patients. The post holder

will be expected to comply with all aspects of the Data Protection Act (1998).

& Diversity Bridgwater Bay PCN is committed

to achieving equality of opportunity for all staff and for those who access

services. You must work in accordance with equal opportunity

policies/procedures and promote the equality and diversity agenda of the PCN.

SafeguardingAll employees have a duty for

safeguarding and promoting the welfare of children and vulnerable adults. Staff

must be aware of the procedure for raising concerns about the welfare of anyone

with whom they have contact.

Health and SafetyEmployees must be aware of the responsibilities

placed on them under the Health & Safety at Work Act 1974, ensure that

agreed safety procedures are carried out and maintain a safe environment for

employees, patients and visitors.

Management The post holder has

responsibility for the timely and accurate creation, maintenance and storage of

records in accordance with policy, including email documents and regarding the

Data Protection Act, The Freedom of Information Act and any other relevant statutory

Governance The post holder will be expected to participate

in clinical governance activities to assist the PCN to provide high quality

services.

Prevention and Control of

Healthcare Associated Infection The post holder is expected to

comply with Infection Control Policies and conduct themselves at all times in

such a manner as to minimise the risk of healthcare associated infection.

Policies

& Procedures Employees are expected to follow

policies, procedures and guidance as well as professional standards and

guidelines.

This post is subject to the Rehabilitation of Offenders Act (Exceptions

Order) 1975 and as such it will be necessary for a submission for Disclosure to

be made to the Disclosure and Barring Service (formerly known as CRB) to check

for any previous criminal convictions.

Bridgwater Primary Care Network (PCN) is the largest PCN in Somerset

with 9 GP practices, a health & wellbeing hub and a diverse population

spread across town and rural locations.

As a PCN we are forward

thinking, innovate and driven to deliver the best patient care for our

population. This includes health population management, and this role ties in

with supporting that and tracking the improvements we can make to patients

lives.

The focus of the hub is

preventative care and supporting self-care management to the population.

Qualifications

Essential: - NMC Registration

Desirable: - Diplomas in care of patients with Diabetes, asthma / copd; - Non medical prescribing qualification

Knowledge and Communication

Essential: - - understanding of proactive care and frailty models; - - strong communication skills

Desirable: - data interpretation for improved patient outcomes.

Experience

Desirable: - Experience in working in Primary care.; - Experience of EMIS and commonly used IT systems; - care home or community experience