Long Term Conditions Nurse / Acp

Bridgwater Bay Primary Care Network; Wedmore; On-site; GBP 36,000 - 52,000; Full time

Job summary

Bridgwater Bay PCN is seeking a Long-term conditions nurse/ACP to deliver anticipatory, personalised care for patients with LTCs and frailty across community and care homes. You will work within an umbrella of MDTs to reduce deteriorations and support independent living.

The role requires managing conditions such as diabetes, COPD, heart failure and multimorbidity, with focus on proactive planning, equity and patient experience within NHS settings.

Qualifications

• NMC registration and current UK practice.
• Diplomas in care of patients with Diabetes, asthma or COPD.
• Experience in proactive care and frailty models.

Responsibilities

• Identify and stratify patients using validated tools (e.g., eFI, Rockwood).
• Conduct comprehensive biopsychosocial assessments including cognition and mobility.
• Develop and review personalised care plans with patients, families and MDTs.
• Monitor early signs of deterioration and intervene to prevent crises.
• Facilitate advance care planning and DNACPR discussions.
• Collaborate with care home staff, community matrons, and social care teams.
• Participate in MDT meetings and integrated neighbourhood team work.
• Maintain accurate documentation and contribute to PCN dashboards.

Skills

Proactive care & frailty models

Data interpretation

Patient Goals & MDT collaboration

EMIS

Care home/community experience

Education

Diplomas in care of patients with Diabetes, asthma / COPD

Tools

EMIS

IT systems

Job description

Job summary

An excellent opportunity has arisen for a Long-term condition nurse or ACP.

This role will play a key role in delivering anticipatory, personalized care for patients living with long-term conditions and frailty across community and care home settings. With a clinical background in managing conditions such as diabetes, COPD, heart failure, and multimorbidity, the postholder will reduce avoidable deterioration, support independent living, and improve quality of life through holistic assessment, care coordination, and early intervention. Working within an integrated multidisciplinary team, the nurse will champion continuity, equity, and proactive planning particularly for vulnerable and housebound cohorts.

One of the main aims of the proactive care team is to help reduce unplanned hospital admissions and A&E attendances.

As an autonomous practitioner, the successful candidate will ideally be a non-medical prescriber, able to demonstrate critical thinking and decision-making relating to long term conditions.

We welcome applications from individuals who enjoy providing outstanding patient care, have a keen interest in being part of a team, striving to improve patient experience and outcomes, with excellent communication and IT skills.

We are also happy to consider applications from individuals who are already employed by other NHS organisations and explore secondment opportunities for the right candidate with that organization.

Main duties of the job

Clinical Practice

• Identify and stratify patients with moderate to severe frailty using validated tools (e.g. eFI, Rockwood)
• Conduct comprehensive biopsychosocial assessments, including cognition, mobility, nutrition, and social support
• Apply specialist knowledge in managing long-term conditions, such as Diabetes, Respiratory Disease and/or cardiovascular conditions.
• Develop and review personalised care and support plans in collaboration with patients, families, and MDTs
• Monitor for early signs of deterioration and intervene to prevent crisis or hospital admission
• Facilitate advance care planning, DNACPR discussions, and end-of-life care coordination
• Work closely with care home staff, community matrons, geriatricians, ARRS roles, and social care teams
• Participate in MDT meetings and contribute to integrated neighbourhood team (INT) working
• Liaise with voluntary sector partners and social prescribing link workers to address non-clinical needs

Quality & Improvement

• Maintain accurate, timely documentation in shared care records and contribute to PCN dashboards
• Use data to identify equity gaps and target interventions for low-uptake or high-risk cohorts
• Contribute to service evaluation, patient feedback, and continuous improvement initiatives
• Support education and training for care home staff and carers around frailty and LTC management

About us

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.

Job responsibilities

Main duties of the job

Job Summary

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

Management of long term conditions which could include:

• Frailty
• Diabetes
• Respiratory
• - Asthma
• - COPD

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.

Confidentiality

The 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).

Equality & 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.

Safeguarding

All 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.

Risk Management / Health and Safety

Employees 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.

Records 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 requirements.

Clinical 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.

Disclosure and Barring Service Check

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.

Person Specification

Qualifications

Essential

• NMC Registration
• Diplomas in care of patients with Diabetes, asthma / copd

Knowledge and Communication

Essential

• understanding of proactive care and frailty models
• data interpretation for improved patient outcomes.
• Experience of working with patients to achieve goals specific to their health needs.
• Experience in helping patients to manage their long term conditions, specifically Diabetes and respiratory conditions
• Ability to liaise with the wider multidisciplinary team to help the patient achieve their goals.
• Experience in working in Primary care.
• Experience of EMIS and commonly used IT systems
• care home or community experience

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

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Long Term Conditions Nurse / ACP • Bridgwater, United Kingdom