York Road PCN LTC Proactive Care Nurse

Long-Term Conditions (LTC) Proactive Care Nurse will work as part of the PCN

Proactive Care Team to provide proactive, evidence-based assessment, management

and care planning for patients living with complex long-term conditions and

frailty across the Primary Care Network. The role is not practice-based and

will operate across the PCN footprint, providing support in patients' own

homes, care homes and community settings.

The post

holder will work with some of the PCN's most frail, vulnerable and clinically

complex patients, undertaking holistic assessments, coordinating care,

supporting self-management, reducing health inequalities and preventing

avoidable hospital admissions.

successful candidate must demonstrate existing knowledge, qualifications,

experience and competency in the management of Diabetes, Respiratory Disease

(Asthma and COPD), Heart Failure and Cardiovascular Disease. The post holder

will be expected to independently undertake Long-Term Condition Part 2 Reviews

from commencement in post and manage complex patients with multiple

SECTION A: MAIN DUTIES AND RESPONSIBILITIES

1.1

Assess, plan, implement and evaluate care plans for patients with complex long-term conditions, promoting proactive independence and self-management whilst working within a multidisciplinary team.

1.2

Build and continually advance clinical knowledge, skills and competence through evidence-based education and professional development.

1.3

Provide specialist advice and support to colleagues regarding the management of long-term conditions and proactive care.

1.4

Work collaboratively with GPs, practice nurses, pharmacists, care coordinators and community services to provide joined-up patient care.

1.5

Demonstrate clinical effectiveness through evidence-based practice, quality improvement activity and outcome monitoring.

1.6

Undertake comprehensive clinical assessments, history taking, examination, clinical decision making and management planning.

1.7

Recognise, assess and manage clinical risk, escalating concerns appropriately and acting within scope of practice.

1.8

Maintain responsibility for patient safety through knowledge of clinical systems, legal requirements and professional accountability.

1.9

Communicate effectively with patients, carers and professionals regarding highly sensitive and complex clinical information.

1.10

Evaluate care outcomes and contribute to service improvement through audit, review and quality assurance processes.

1.11

Independently manage patients with Diabetes Mellitus, Cardiovascular Disease, Heart Failure and Respiratory Conditions including Asthma and COPD.

1.12

Undertake and complete Long-Term Condition Part 2 Reviews in accordance with local and national guidance.

1.13

Interpret clinical investigations relevant to LTC management including blood results, cardiovascular risk assessments, diabetes monitoring indicators, ECG findings where appropriate and respiratory assessments.

1.14

Develop, implement and review personalised management plans for patients with single and multiple long-term conditions.

1.15

Identify patients requiring proactive intervention through risk stratification and clinical review to reduce disease progression and prevent avoidable hospital admissions.

1.16 To undertake home visits and care home visits across the PCN footprint to assess and manage patients who are unable to access routine primary care services due to frailty, vulnerability, complexity or deteriorating health status.

2.1

Demonstrate leadership qualities and support the ongoing development and improvement of LTC services across the PCN.

2.2

Support service redesign and change management initiatives.

2.3

Act as a role model, promoting positive, professional and collaborative behaviours.

3. RESPONSIBILITY FOR HUMAN RESOURCES / WORKFORCE

3.1

Provide clinical support and guidance to colleagues.

3.2

Support and mentor junior members of staff.

3.3

Participate in teaching, training and competency assessment where required.

4. RESEARCH AND DEVELOPMENT

4.1

Participate in audits, service evaluations and quality improvement initiatives.

4.2

Maintain awareness of current developments in long-term condition management and primary care practice.

5. POLICY AND SERVICE DEVELOPMENT

5.1

Contribute to the development and implementation of policies, pathways and protocols relating to long-term conditions.

An exciting opportunity has arisen for a Long-Term Conditions (LTC) Proactive

Care Nurse to support York Road Primary Care Network (PCN). York Road PCN

includes 3 practices working over 5 sites: Shaftesbury Medical Centre, Church

View Surgery, Garden Surgery, The Medical Centre (Rookwood Ave) & The

Medical Centre (846 York Road) and you will be expected to provide support and

care to patients registered across all the practices in the PCN, including

those within our 3 Care Homes

BUSINESS TRAVEL

Essential: - Ability to travel independently throughout the PCN footprint; - Access to a vehicle suitable for business use and a full driving licence

PERSONAL QUALITIES / ATTRIBUTES

Qualifications

Desirable: - History Taking and Physical Examination (HAPE).; - Enhanced Clinical Assessment qualification.; - Non-Medical Prescribing qualification.

Ref MANAGERIAL / SUPERVISORY EXPERIENCE

Essential: - Experience of providing support, supervision or mentoring to colleagues; - Experience of teaching or delivering training

INFORMATION TECHNOLOGY / RESOURCES

Essential: - Experience using electronic patient records and clinical systems; - Good working knowledge of Microsoft Office applications

Desirable: - Experience using population health management and risk stratification tools

Experience

Additional requirements