This permanent post sits with Allied Health South Lincolnshire for the South Lincs and Rural Primary Care Network, based in GP practices. The core of the work is case-managing people at risk of unplanned hospital admission, working alongside practice staff and the Neighbourhood Team to keep them supported in their community. The post is 0.6 WTE over three days a week, with regular visits to care homes and housebound patients every three to six months. Fit depends on NMC registration and experience of long-term conditions.
What the job involves
- Proactively case-manage people at high risk of hospital admission, acting as their preferred point of contact
- Assess people at home, in care homes and in the community, and implement and review their individual care plans
- Visit people after urgent clinical need or unplanned admission, and those with repeat admissions, within two weeks
- Plan visits every three to six months to housebound people and to nursing and residential homes, providing training as required
- Ensure all people in care homes and all people with dementia have a care plan
- Diagnose, treat, prescribe and refer within own registration and competence, at home or in practice
- Liaise with GPs, practice teams, hospital, specialist, community and social care services and other agencies
- Support self-management, signpost people to local services, and help them access community care and carers assessments
- Identify unpaid carers and **escalate** urgent need or safety concerns to the Neighbourhood Team
- Contact people following a bereavement and follow up communications from out-of-hospital and inpatient services
- Attend practice multidisciplinary and Neighbourhood Team meetings
- Keep accurate records on GP systems, run patient searches and support KPI reporting for the practice
What’s required
Qualifications
- Registered Nurse Level 1
- Post-graduate study in health-related studies relevant to long-term conditions, or equivalent experience
- Evidence of continuing professional development
- Post-registration teaching qualification, or willingness to undertake one
- Post-registration qualification in non-medical prescribing, or willingness to undertake one as service needs change
Registration & licences
Experience
- Experience of dealing with people with long-term conditions
- Evidence of working autonomously
- Evidence of working within a multidisciplinary team
What’s offered
- 30 days annual leave plus 8 bank holidays, pro rata
- Sickness pay aligned with AFC terms
- NHS Pension or NEST pension
- Employee assistance programme