About this role
Job summary
This is an exciting new post within our Primary Care Network, focused on supporting patients to remain well and independent in their own homes.
The Admission Prevention Nurse will provide a proactive, preventative and responsive nursing service for patients at greatest risk of deterioration, urgent care use and unplanned hospital admission. The role will have a particular focus on the PCNs highest-risk population, including patients identified within the top 1% risk of hospital admission.
Using population health intelligence, clinical judgement and referrals from primary care and neighbourhood partners, the postholder will identify patients who may benefit from early intervention. They will provide holistic assessment, proactive care planning, clinical intervention and monitoring, helping patients maintain their health, independence and wellbeing at home wherever clinically appropriate.
Working closely with GPs, community and frailty teams, social care, pharmacy, mental health, secondary care and other neighbourhood partners, the postholder will help coordinate care and reduce fragmentation for patients with complex needs.
The role supports the NHS ambition to shift care from hospital to community and from sickness to prevention, strengthening neighbourhood working and reducing avoidable deterioration and hospital admission.
As this is a new role, we have flexibility to shape the working pattern around both the needs of the service and the successful candidate.
Main duties of the job
The Admission Prevention Nurse will provide proactive, personalised care to patients at greatest risk of deterioration and hospital admission, working with patients, carers and their wider support networks to understand what matters to them and support independence at home.
As a senior autonomous clinician, you will undertake holistic assessment, identify emerging risks, develop proactive care plans and coordinate appropriate clinical interventions. You will work closely with GPs and wider primary, community, secondary and social care teams to ensure patients with complex needs receive joined-up care and timely support.
You will provide clinical oversight for admission prevention within the PCN, acting as a clinical resource for colleagues and supporting the development of effective pathways across organisational boundaries. You will identify gaps, duplication and barriers within existing services and contribute to strengthening integrated neighbourhood working.
As this is a developing service, you will also play an important role in shaping and evaluating the model. This will include monitoring patient outcomes and urgent care use, maintaining accurate activity data, contributing to audit and quality improvement, gathering feedback and using case learning and data to demonstrate impact and continually improve the service.
About us
Healthier West Wirral Primary Care Network is an ambitious and forward-thinking organisation serving over 70,000 patients across five GP practices on the west side of the Wirral Peninsula.
We are committed to delivering high-quality, patient-centred care by developing innovative services that meet the changing needs of our local population. Our focus is on providing proactive, integrated care closer to home, improving patient outcomes while supporting the sustainability of primary care.
Our multidisciplinary team includes GPs, nurses, clinical pharmacists, pharmacy technicians, physician associates, care coordinators and social prescribers, all working collaboratively to deliver seamless care across our communities.
As the NHS continues its shift towards neighbourhood healthcare, we are proud to be developing new models of care and creating opportunities for clinicians to shape services, develop specialist interests and make a real difference. If you're looking for a role where you can innovate, collaborate and influence the future of primary care, we'd love to hear from you.
Job description Job responsibilities
Key Responsibilities
Proactive Case Finding and Admission Prevention
Use available population health, risk-stratification and clinical information to identify patients at greatest risk of deterioration and unplanned hospital admission. Maintain a particular focus on the PCN's highest-risk cohort, including patients identified within the top 1% risk of admission. Accept and clinically triage referrals from GPs, PCN clinicians, community teams and other appropriate neighbourhood partners. Proactively contact patients rather than relying solely on patients presenting to services when their health has deteriorated. Identify emerging deterioration, unmet need and modifiable risk factors at the earliest opportunity. Develop individualised plans aimed at maintaining patients safely within their usual place of residence wherever clinically appropriate. Identify recurrent patterns of emergency department attendance, hospital admission or crisis and work with patients, families and professionals to address potentially preventable causes.
Advanced Clinical Assessment
Undertake comprehensive and holistic assessment of patients with complex health and care needs within their own homes, GP practices and other appropriate community settings. Assess physical health, frailty, functional ability, cognition, medication, nutrition, falls risk, social circumstances and other factors affecting a patient's ability to remain well at home. Recognise signs of acute deterioration and exercise autonomous clinical judgement regarding appropriate intervention and escalation. Undertake relevant clinical observations and assessments within professional competence. Identify red flags requiring urgent medical assessment or escalation and act appropriately. Develop and review personalised care and support plans in partnership with patients, carers and other professionals. Support anticipatory care planning for patients at increased risk of deterioration or crisis.
Clinical Intervention and Management
Provide nursing interventions within the postholder's professional competence to prevent deterioration and support recovery at home. Monitor patients following episodes of deterioration and provide appropriate short-term enhanced support where this may prevent escalation to hospital. Support optimisation of long-term conditions in collaboration with the patient's GP and relevant specialist services. Undertake medication review and medicines-related assessment within professional competence, working closely with GPs, PCN pharmacists and other prescribers. Identify and address factors contributing to poor health outcomes, including adherence, nutrition, hydration, mobility, falls, social isolation and ability to self-manage. Provide education and advice to patients and carers to improve recognition of deterioration and support appropriate self-management. Working within the wider PCN nursing team when required to support general nursing work including seasonal vaccination. Ensure appropriate safety-netting and escalation arrangements are in place.
Care Coordination and Neighbourhood Working
Act as a key clinical coordinator for patients whose complexity requires input from multiple services. Work collaboratively with general practice, community nursing, frailty services, social care, pharmacy, mental health, therapy services, secondary care and voluntary/community organisations. Participate actively in PCN and neighbourhood multidisciplinary team meetings. Ensure that patients are connected with existing services wherever these can appropriately meet identified needs, avoiding unnecessary duplication. Facilitate rapid communication between services where deterioration or emerging risk is identified. Support effective transfer of care following hospital discharge where early intervention may reduce the risk of readmission. Develop effective professional relationships across organisational boundaries to support increasingly integrated neighbourhood working. Identify gaps, duplication and barriers within existing pathways and contribute to developing more effective admission-prevention pathways.
Personalised and Preventative Care
Place the patient and their individual goals at the centre of assessment and care planning. Support patients to maintain independence and remain within their preferred place of care wherever safe and appropriate. Take a strengths-based approach, recognising the capabilities of patients, carers and their wider support networks. Identify opportunities for prevention and early intervention rather than responding only once a patient reaches crisis. Recognise wider determinants affecting a patient's health and ability to remain well at home and facilitate access to appropriate support. Promote shared decision-making and support patients to make informed decisions about their care.
Clinical Leadership
Provide visible clinical leadership for proactive admission prevention within the PCN. Act as a senior clinical resource for colleagues managing patients at high risk of admission. Promote a proactive rather than reactive approach to the management of complex and vulnerable patients. Support the development of effective pathways between primary care, community services and secondary care. Provide professional advice and education to PCN colleagues within the postholder's areas of expertise. Contribute to the development of the PCN's wider proactive care, frailty and neighbourhood strategy. Support the development of a culture in which admission prevention is viewed as a shared responsibility across the neighbourhood multidisciplinary team. Act as a PCN representative at meetings, stakeholder events and community engagement initiatives. As a developing model of care, demonstrating the impact of the service will be a key responsibility of the postholder.
Data
contribute to establishing baseline measures and outcome indicators for the service. maintain accurate activity, coding and outcome data. monitor interventions and patient outcomes. contribute to audit and quality-improvement activity with the support of the digital transformation lead. review patterns of admission and urgent care utilisation within the target cohort; identify learning from cases where admission was successfully avoided and where patients subsequently required hospital care. obtain and respond to patient, carer and professional feedback; contribute to regular evaluation and refinement of the service model; and provide reports and case studies demonstrating service activity, outcomes and learning.
Person Specification
Qualifications Essential
Essential Registered Nurse with current NMC registration. Evidence of relevant post-registration professional development. Evidence of advanced clinical assessment skills relevant to the management of adults with complex needs. Experience Significant post-registration experience within primary care, community nursing, urgent care, frailty, acute medicine or another relevant clinical environment. Experience of independently assessing and managing patients with complex and multiple health needs. Experience of recognising and responding to acute deterioration. Experience of multidisciplinary and multi-agency working. Experience of managing clinical risk and making autonomous clinical decisions. Experience of working with patients with multiple long-term conditions and/or frailty. Knowledge and skills Strong understanding of admission prevention, proactive care and management of patients with complex needs. Advanced assessment and clinical decision-making skills. Ability to prioritise and independently manage a complex caseload. Ability to recognise clinical deterioration and determine appropriate escalation. Excellent communication and interpersonal skills. Ability to coordinate care across organisational and professional boundaries. Understanding of safeguarding adults and relevant legal and professional responsibilities. Understanding of personalised care, health inequalities and reasonable adjustments. Ability to use clinical IT systems and interpret population health and patient-level information. Ability to contribute to service evaluation, audit and quality improvement.
Desirable
Independent or supplementary prescribing qualification. Advanced Clinical Practice qualification or relevant Master's-level study. Experience in frailty, community matron, virtual ward, hospital-at-home, urgent community response or admission-avoidance services. Experience of primary care and/or Primary Care Networks. Experience of population health management or risk-stratification approaches. Experience of service development or establishing a new clinical pathway. Knowledge of the local health, social care and voluntary-sector landscape.
Disclosure and Barring Service Check This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
UK Registration
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).
Employer details Employer name Healthier West Wirral Primary Care Network
Address 156 Common Field Road
Woodchurch
Birkenhead
CH49 7LP
United Kingdom
Employer's website https://healthierwestwirralpcn.co.uk/ (Opens in a new tab)