Proactive LTC Care Nurse - Home Visits & Coordination

NHS Jobs; Leeds; On-site; GBP 32,000 - 42,000; Full time

Job summary

NHS Jobs in Leeds is seeking a clinician to deliver proactive long-term condition care within a PCN. You will assess, plan and manage care for patients with complex conditions, and work with GPs, nurses, pharmacists and community services to coordinate patient care.

The role requires ongoing professional development, adherence to safety standards and active participation in audits and quality improvement projects across the primary care network.

Responsibilities

• Assess, plan, implement and evaluate care plans for patients with complex long-term conditions.
• Build and continually advance clinical knowledge, skills and competence through evidence-based education and professional development.
• Provide specialist advice and support to colleagues regarding the management of long-term conditions and proactive care.
• Work collaboratively with GPs, practice nurses, pharmacists, care coordinators and community services to provide joined-up patient care.
• Demonstrate clinical effectiveness through evidence-based practice, quality improvement activity and outcome monitoring.
• Undertake comprehensive clinical assessments, history taking, examination, clinical decision making and management planning.
• Recognise, assess and manage clinical risk, escalating concerns appropriately and acting within scope of practice.
• Maintain responsibility for patient safety through knowledge of clinical systems, legal requirements and professional accountability.
• Communicate effectively with patients, carers and professionals regarding highly sensitive and complex clinical information.
• Evaluate care outcomes and contribute to service improvement through audit, review and quality assurance processes.
• Independently manage patients with Diabetes Mellitus, Cardiovascular Disease, Heart Failure and Respiratory Conditions including Asthma and COPD.
• Undertake and complete Long-Term Condition Part 2 Reviews in accordance with local and national guidance.
• Interpret clinical investigations relevant to LTC management including blood results, cardiovascular risk assessments, diabetes monitoring indicators, ECG findings where appropriate and respiratory assessments.
• Develop, implement and review personalised management plans for patients with single and multiple long-term conditions.
• Identify patients requiring proactive intervention through risk stratification and clinical review to reduce disease progression and prevent avoidable hospital admissions.
• 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.

Job description

NHS Jobs in Leeds is seeking a clinician to deliver proactive long-term condition care within a PCN. You will assess, plan and manage care for patients with complex conditions, and work with GPs, nurses, pharmacists and community services to coordinate patient care.

The role requires ongoing professional development, adherence to safety standards and active participation in audits and quality improvement projects across the primary care network.