York Road PCN LTC Proactive Care Nurse

The Methodist Church in Britain; 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

This part-time post sits in the Proactive Care Team of York Road Primary Care Network, serving patients across all its practices and three care homes. The nurse assesses and manages complex long-term conditions and frailty, coordinating care to prevent avoidable hospital admissions. The work is not practice-based: it involves travelling across the network to see patients at home, in care homes and in the community. Applicants must hold NMC registration and already be competent in diabetes, respiratory disease, heart failure and cardiovascular disease.

What the job involves

• Assess, plan, implement and review care plans for patients with complex long-term conditions, promoting self-management
• Independently manage patients with diabetes, cardiovascular disease, heart failure, asthma and COPD
• Undertake annual LTC reviews and Long-Term Condition 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

What’s required

Qualifications

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

Registration & licences

• NMC registration as a registered nurse

Experience

• Band 5 level or above
• Significant recent long-term condition management in primary care, including complex co-morbidities
• Independent annual LTC reviews, and ability to undertake Part 2 Reviews from appointment
• Providing supervision, mentoring or teaching to colleagues

Skills & knowledge

• Excellent written and spoken English communication, including highly complex and sensitive information
• Working autonomously and using professional judgement
• Strong clinical assessment, decision-making and diagnosis within scope of practice

Checks & eligibility

• Full driving licence and access to a vehicle suitable for business use

Other

• Experience using electronic patient records and clinical systems
• Ability to travel independently and work across all PCN practices, patient homes and care homes

Nice to have

• History Taking and Physical Examination (HAPE)
• Enhanced Clinical Assessment qualification
• Non-Medical Prescribing qualification
• Experience within a Primary Care Network
• Experience undertaking quality improvement projects
• Experience supporting service redesign and transformation
• Experience using population health management and risk stratification tools