York Road PCN LTC Proactive Care Nurse

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

SECTION A: MAIN DUTIES AND RESPONSIBILITIES

1. CLINICAL RESPONSIBILITIES

• 1.1 Assess, plan, implement and evaluate care plans for patients with complex long-term conditions, promoting proactive independence and self-management whilst working within a multidisciplinary team.
• 1.2 Build and continually advance clinical knowledge, skills and competence through evidence-based education and professional development.
• 1.3 Provide specialist advice and support to colleagues regarding the management of long-term conditions and proactive care.
• 1.4 Work collaboratively with GPs, practice nurses, pharmacists, care coordinators and community services to provide joined-up patient care.
• 1.5 Demonstrate clinical effectiveness through evidence-based practice, quality improvement activity and outcome monitoring.
• 1.6 Undertake comprehensive clinical assessments, history taking, examination, clinical decision making and management planning.
• 1.7 Recognise, assess and manage clinical risk, escalating concerns appropriately and acting within scope of practice.
• 1.8 Maintain responsibility for patient safety through knowledge of clinical systems, legal requirements and professional accountability.
• 1.9 Communicate effectively with patients, carers and professionals regarding highly sensitive and complex clinical information.
• 1.10 Evaluate care outcomes and contribute to service improvement through audit, review and quality assurance processes.
• 1.11 Independently manage patients with Diabetes Mellitus, Cardiovascular Disease, Heart Failure and Respiratory Conditions including Asthma and COPD.
• 1.12 Undertake and complete Long-Term Condition Part 2 Reviews in accordance with local and national guidance.
• 1.13 Interpret clinical investigations relevant to LTC management including blood results, cardiovascular risk assessments, diabetes monitoring indicators, ECG findings where appropriate and respiratory assessments.
• 1.14 Develop, implement and review personalised management plans for patients with single and multiple long-term conditions.
• 1.15 Identify patients requiring proactive intervention through risk stratification and clinical review to reduce disease progression and prevent avoidable hospital admissions.
• 1.16 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.

2. MANAGERIAL RESPONSIBILITIES

• 2.1 Demonstrate leadership qualities and support the ongoing development and improvement of LTC services across the PCN.
• 2.2 Support service redesign and change management initiatives.
• 2.3 Act as a role model, promoting positive, professional and collaborative behaviours.

3. RESPONSIBILITY FOR HUMAN RESOURCES / WORKFORCE

• 3.1 Provide clinical support and guidance to colleagues.
• 3.2 Support and mentor junior members of staff.
• 3.3 Participate in teaching, training and competency assessment where required.

4. RESEARCH AND DEVELOPMENT

• 4.1 Participate in audits, service evaluations and quality improvement initiatives.
• 4.2 Maintain awareness of current developments in long-term condition management and primary care practice.

5. POLICY AND SERVICE DEVELOPMENT

• 5.1 Contribute to the development and implementation of policies, pathways and protocols relating to long-term conditions.

6. INFORMATION AND DATA

• 6.1 Maintain accurate and timely patient records and ensure coding is completed appropriately to support QOF, contract and service requirements.

7. PROFESSIONAL RESPONSIBILITIES

• 7.1 Ensure personal performance meets professional, organisational and regulatory standards.
• 7.2 Maintain the required level of IT competency.
• 7.3 Contribute to service improvement and innovation.
• 7.4 Challenge poor practice and act appropriately when concerns arise.
• 7.5 Promote high-quality, person-centred care.
• 7.6 Foster effective multidisciplinary teamwork.
• 7.7 Promote equality, diversity and inclusion.

8. OTHER RESPONSIBILITIES

• 8.1 Work as an integral member of the PCN Proactive Care Team, supporting delivery of proactive care services across all practices within the PCN.
• 8.2 Provide proactive assessment, management and monitoring for patients with complex long-term conditions including: Diabetes Mellitus Cardiovascular Disease Heart Failure Asthma Chronic Obstructive Pulmonary Disease (COPD)
• 8.3 Undertake annual LTC reviews and Long-Term Condition Part 2 Reviews, developing evidence-based management plans and supporting optimisation of treatment.
• 8.4 Provide holistic assessment and care planning for frail and vulnerable patients with complex physical, psychological and social needs.
• 8.5 Undertake home visits and care home visits across the PCN footprint, delivering proactive care to patients who are housebound, residing in care homes, or unable to attend primary care premises.
• 8.6 Work collaboratively with GPs, pharmacists, social prescribers, care coordinators, community nursing teams, secondary care services and care home staff to coordinate care and improve outcomes.
• 8.7 Identify patients at risk of deterioration, hospital admission or increasing dependency and implement proactive interventions to reduce risk.
• 8.8 Support the delivery of personalised care planning, anticipatory care planning and admission avoidance strategies.
• 8.9 Recognise deteriorating patients and respond appropriately.
• 8.10 Work flexibly across the PCN footprint to meet the operational requirements of the Proactive Care Team.