Proactive Care Nurse Home and Community Visits

South and East Leeds GP Group; Leeds; On-site; GBP 25,000 - 36,000; Part time

Job summary

The York Road Primary Care Network is looking for a part-time nurse to join the Proactive Care Team. You will travel across practices, care homes, and patients’ homes to assess and manage those with complex long-term conditions, coordinating care with GPs and other teams.

You will require NMC registration and proven competency in diabetes, respiratory disease, heart failure, and cardiovascular disease, with a focus on complex co-morbidities and evidence-based care planning.

Qualifications

• Accredited training in diabetes management.
• Accredited training in respiratory disease management (asthma/COPD).
• Accredited training in heart failure management.
• Accredited training in cardiovascular disease management.
• Evidence of ongoing professional development.

Responsibilities

• Assess, plan, implement and review care plans for patients with complex long-term conditions.
• Independently manage diabetes, cardiovascular disease, heart failure, asthma and COPD.
• Undertake annual LTC reviews and Part 2 Reviews to local and national guidance.
• Make home and care home visits across the PCN to assess and manage patients who cannot attend primary care.
• Provide holistic assessment and care planning for frail patients with physical, psychological and social needs.
• Identify patients at risk of deterioration or admission, recognise deterioration and intervene proactively.
• Coordinate care with GPs, pharmacists, social prescribers, community and secondary care teams and care home staff.
• Interpret clinical investigations including blood results, cardiovascular risk assessments, ECGs and respiratory assessments.
• Support personalised and anticipatory care planning and admission avoidance strategies.
• Give clinical advice to colleagues and support, mentor and teach junior staff.
• Contribute to audit, quality improvement, service redesign and policy and protocol development.
• Keep accurate patient records and coding to support QOF and contract requirements

Skills

English communication

Autonomous working

Clinical assessment

Decision making

Diagnosis

Driving licence

Travel for work

Education

Diabetes management competency

Respiratory disease management competency

Heart failure management competency

Cardiovascular disease management competency

Job description

The York Road Primary Care Network is looking for a part-time nurse to join the Proactive Care Team. You will travel across practices, care homes, and patients’ homes to assess and manage those with complex long-term conditions, coordinating care with GPs and other teams.

You will require NMC registration and proven competency in diabetes, respiratory disease, heart failure, and cardiovascular disease, with a focus on complex co-morbidities and evidence-based care planning.