Frailty & Proactive Care NP — Lead Assessments

NHS Jobs; Pennsylvania; On-site; USD 115,000 - 145,000; Full time

Job summary

NHS Jobs is seeking an Advanced Nurse Practitioner to lead frailty and proactive care across an integrated practice network. The role focuses on comprehensive geriatric assessments, holistic care planning and collaboration with GPs, pharmacists and care teams.

The post involves coordinating home visits, reviews for housebound patients and care homes, plus contributing to service development and workforce training. A registered APN with prescribing rights is expected.

Responsibilities

• Undertake advanced clinical assessment of patients with frailty, complex needs and multiple long-term conditions.
• Provide holistic assessment including physical, psychological, functional and social needs.
• Undertake Comprehensive Geriatric Assessments (CGA).
• Diagnose and manage acute and chronic conditions within professional competence.
• Independently prescribe medication where qualified and appropriate.
• Develop personalised care and support plans.
• Complete anticipatory care planning and advance care planning discussions.
• Undertake home visits for housebound and vulnerable patients.
• Support care home residents through regular clinical reviews.
• Identify patients at risk of deterioration, admission or crisis and implement preventative interventions.
• Participate in multidisciplinary case management meetings.
• Lead the identification of patients living with moderate and severe frailty using risk stratification tools and clinical judgement.
• Support delivery of proactive care and personalised care programmes.
• Develop pathways for frailty management and prevention.
• Coordinate care for patients with complex needs and frequent hospital admissions.
• Promote healthy ageing and independence.
• Provide clinical leadership for integrated services across the PCN.
• Support service redesign and quality improvement initiatives.
• Participate in audit, evaluation and service development projects.
• Support implementation of local and national priorities relating to frailty.
• Contribute to workforce development and training of other healthcare professionals.
• Work collaboratively with GPs, Clinical Pharmacists, Social Prescribers, Care Coordinators, Community Nurses, Therapists and Social Care teams.
• Attend multidisciplinary team meetings and neighbourhood team meetings.

Job description

NHS Jobs is seeking an Advanced Nurse Practitioner to lead frailty and proactive care across an integrated practice network. The role focuses on comprehensive geriatric assessments, holistic care planning and collaboration with GPs, pharmacists and care teams.

The post involves coordinating home visits, reviews for housebound patients and care homes, plus contributing to service development and workforce training. A registered APN with prescribing rights is expected.