PCN Frailty Nurse/ANP

Denton Park Medical Group; Newcastle upon Tyne; On-site; GBP 30,000 - 40,000; Full time

Job summary

A local healthcare provider in Newcastle upon Tyne is seeking a Frailty Nurse to support and improve the health of frail, housebound patients. Responsibilities include assessing health needs, managing chronic conditions such as diabetes and hypertension, and collaborating with a multidisciplinary team. Requires experience in primary care and strong communication skills. This full-time role offers a chance to make a significant impact on patient care within a community-focused environment.

Benefits

Supportive team environment

Opportunities for professional development

Qualifications

• Experience of working in a primary care environment.
• Ability to work autonomously and as part of a team.
• Competent in the use of clinical documentation systems.

Responsibilities

• Visit patients at home to assess health needs.
• Provide ongoing management of chronic conditions.
• Support health promotion and self-management strategies.

Skills

Excellent communication skills

Teamwork

Problem solving

Time management

Chronic disease management

Education

Registered Nurse

Post graduate diploma or degree (primary care)

Tools

EMIS

Office and Outlook

Job description

The specific purpose of the post is to support and improve the health and wellbeing of our frail, housebound patients. This will have a focus on long-term medicalconditions such as diabetes, hypertension, and cardiovascular disease, but will also aim to take a wider holistic view, including providing information, advice,or referrals to other services.

The post holder will work within a PCN frailty team includinga health care assistant (HCA), social prescriber (SPLW) and a GP frailty leadbut will also liaise closely with the clinicians at each of the practiceswithin the OW Primary Care Network (PCN) and other members of the broader PCNteam.

The clinical part of the role will primarily involve visitingpatients in their own home, using a person-centred approach to undertake a comprehensiveneeds assessment. This will involve takinga detailed history and formulating a simple management plan based on thisinformation together with the results of simple investigations (e.g. bloodpressure and blood results) that have been performed in advance by theHCA. Such management will typicallyfollow protocols and medical guidelines for the relevant conditions and will beguided by GP input when required.

The role does NOT involve the assessment andmanagement of acutely unwell patients

Main duties of the job

Coreresponsibilities of the frailty nurse.To visit patients at home as part of the OW PCNfrailty team.

To make a comprehensive holistic assessment ofhealth and wellbeing needs, including history taking and simple investigations.

To recognise situations that may be detrimentalto the health and well-being of the individual and act on the findings.

To provide ongoing management of long-termconditions, such as diabetes, COPD, hypertension, and cardiovascular disease.

To support and advise patients on the promotionof health, prevention of ill-health and the self-management of their healthwithin their own abilities.

To undertake comprehensive care planningincluding Emergency Health Care Planning (EHCP).

To provide general and specific healthscreenings to the patients with referral to GPs asnecessary.

To ensure proactive and early case management offrail patients with complex needs to prevent unnecessary hospitaladmissions/readmissions.

To maintain effective communication with GPpractice and other appropriate healthcare teams to the benefit of the patient.

To support the HCA and SPLW, providing guidancewhen necessary.

About us

Primary Care Networks (PCNs) were introduced into the NHS in 2019. Essentially, it is a group of GP Practices working together. They share resources and specialist staff, meaning each Practice and their patients benefit from additional services that individual practices couldn't provide independently.

The Outer West PCN is a collaboration between Newburn, Denton Turret, Denton Park, Throckley, Parkway and Westerhope GP surgeries in Newcastle upon Tyne. Oversight and management are provided by the Clinical Director and Board, alongside a dedicated PCN Project Manager.

The PCNs vision is to be a collaborative needs-led Network that has provided significant and demonstrable improvement to the health of our population

Job responsibilities

Primaryresponsibilities

The following are the coreresponsibilities of the frailty nurse. There may, on occasion, be a requirementto carry out other tasks dependent upon factors such as workload and staffinglevels. For frail and housebound patients:

To visit patients at home as part of the OW PCNfrailty team.

To make a comprehensive holistic assessment ofhealth and wellbeing needs, including history taking and simple investigations.

To make a targeted clinical assessment ofpatients with newly presenting minor illness and manage appropriately.

To recognise situations that may be detrimentalto the health and well-being of the individual and act on the findings.

To provide ongoing management of long-termconditions, such as diabetes, COPD, hypertension, and cardiovascular disease.

To support and advise patients on the promotionof health, prevention of ill-health and the self-management of their healthwithin their own abilities.

To undertake comprehensive care planningincluding Emergency Health Care Planning.

To provide nursing treatments to patients inparticipation with GPs or independently to agreed practice protocols.

To provide general and specific healthscreenings to the patients (within agreed protocols) with referral to GPs asnecessary.

To provide appropriate signposting to a relevantclinician or external organisation whilst ensuring that the patient receivesappropriate ongoing care.

To ensure that all necessary arrangements arecompleted promptly and in a safe manner.

To ensure proactive and early case management offrail patients with complex needs to prevent unnecessary hospitaladmissions/readmissions.

To maintain clear, concise, and accuratedocumentation within the GP on-line systems provided EMIS and SystemOne.

To communicate complex and sensitive informationconcerning a patients medical condition effectively to patients/carers,recognising that sometimes there are barriers to understanding.

To maintain effective communication with GPpractice and other appropriate healthcare teams to the benefit of the patient.

To support the HCA and SPLW, providing guidancewhen necessary.

To work with and continually seek to develop thePCNs Frailty team.

To maintain knowledge of the context of the roleand how this work seeks to meet Practice and PCN Obligations and Requirements.

To ensure that care given is supported by thebest available evidence and local policies and procedures.

To maintain professional competency whilstremaining current and in date for NMC revalidation.

Secondaryresponsibilities

Inaddition to the primary responsibilities, the frailty nurse may be requestedto:

Participate in audit work, effectively utilisingthe audit cycle

Participate in local initiatives to enhanceservice delivery and patient care

Support and participate in shared learningwithin the practice

Continually review clinical practices,responding to local and national policies and initiatives where appropriate

Participate in the review of significant andnear-miss events applying a structured approach, i.e. root cause analysis

Person Specification

Qualifications

• Registered Nurse
• Experience of working in a primary care environment
• Experience of working as a practice nurse or community nurse
• Experience of chronic disease management
• Excellent communication skills (written and oral)
• Clear, polite telephone manner
• Competent in the use of Office and Outlook
• EMIS and S1 user skills
• Effective time management (planning and organising)
• Ability to work as a team member and autonomously
• Good interpersonal skills
• Problem solving and analytical skills
• Ability to follow clinical policy and procedure
• Experience with audits
• Experience with clinical risk management
• Post graduate diploma or degree (primary care)
• Independent prescriber
• Experience of working within a Primary Care Network or multi-site context.
• Knowledge of public health issues in the local area
• Awareness of issues within the wider health arena

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.