About this role
Job summary
**interviews to be held 29th or 30th October**
JOB DESCRIPTION
JOB TITLE: PCN Long-Term Conditions (LTC) Proactive Care Nurse
LOCATION: York Road PCN
ACCOUNTABLE TO: Clinical Director
LINE MANAGER: PCN Manager
HOURS OF WORK: Part Time
Main duties of the job
ROLE PURPOSE
The PCN Long-Term Conditions (LTC) Proactive Care Nurse will work as part of the PCN Proactive Care Team to provide proactive, evidence-based assessment, management and care planning for patients living with complex long-term conditions and frailty across the Primary Care Network. The role is not practice-based and will operate across the PCN footprint, providing support in patients' own homes, care homes and community settings.
The post holder will work with some of the PCN's most frail, vulnerable and clinically complex patients, undertaking holistic assessments, coordinating care, supporting self-management, reducing health inequalities and preventing avoidable hospital admissions.
The successful candidate must demonstrate existing knowledge, qualifications, experience and competency in the management of Diabetes, Respiratory Disease (Asthma and COPD), Heart Failure and Cardiovascular Disease. The post holder will be expected to independently undertake Long-Term Condition Part 2 Reviews from commencement in post and manage complex patients with multiple
About us
An exciting opportunity has arisen for a Long-Term Conditions (LTC) Proactive Care Nurse to support York Road Primary Care Network (PCN). York Road PCN includes 3 practices working over 5 sites: Shaftesbury Medical Centre, Church View Surgery, Garden Surgery, The Medical Centre (Rookwood Ave) & The Medical Centre (846 York Road) and you will be expected to provide support and care to patients registered across all the practices in the PCN, including those within our 3 Care Homes
Job description Job responsibilities
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.
Person Specification
BUSINESS TRAVEL Essential
Ability to travel independently throughout the PCN footprint Access to a vehicle suitable for business use and a full driving licence
PERSONAL QUALITIES / ATTRIBUTES Essential
Excellent communication and interpersonal skills Ability to communicate highly complex and sensitive information effectively Ability to work autonomously and use professional judgement Strong clinical assessment and decision-making skills Ability to prioritise and manage workload across a large geographical area Excellent communication and interpersonal skills Ability to communicate highly complex and sensitive information effectively Ability to work autonomously and use professional judgement Strong clinical assessment and decision-making skills Ability to prioritise and manage workload across a large geographical area
Qualifications Essential
Registered Nurse (NMC). Evidence of ongoing professional development. Accredited training and competency in Diabetes management. Accredited training and competency in Respiratory Disease management (Asthma/COPD). Accredited training and competency in Heart Failure management. Accredited training and competency in Cardiovascular Disease management. Ability to independently undertake Long-Term Condition Part 2 Reviews. Excellent communication and clinical assessment skills. Competence in chronic disease management and care planning.
Desirable
History Taking and Physical Examination (HAPE). Enhanced Clinical Assessment qualification. Non-Medical Prescribing qualification.
Ref MANAGERIAL / SUPERVISORY EXPERIENCE Essential
Experience of providing support, supervision or mentoring to colleagues Experience of teaching or delivering training
INFORMATION TECHNOLOGY / RESOURCES Essential
Experience using electronic patient records and clinical systems Good working knowledge of Microsoft Office applications
Desirable
Experience using population health management and risk stratification tools
Experience Essential
Experience working at Band 5 level or above. Significant recent experience managing long-term conditions within primary care. Experience undertaking annual LTC reviews independently. Experience managing patients with complex co-morbidities. Experience managing Diabetes, Respiratory Disease, Heart Failure and Cardiovascular Disease. Ability to independently assess, diagnose and formulate management plans within scope of practice. Strong organisational and workload management skills.
Desirable
Experience within a Primary Care Network. Experience undertaking quality improvement projects. Experience supporting service redesign and transformation.
additional requirements Essential
Candidates must be able to demonstrate current competency, relevant qualifications and practical experience in Diabetes, Respiratory Disease, Heart Failure and Cardiovascular Disease management. Due to the complexity of the patient cohort, the post holder must be capable of independently undertaking Long-Term Condition Part 2 Reviews from appointment. Ability to work across all PCN member practices, patient homes and care homes Ability to work as part of the PCN Proactive Care Team rather than being based within a single practice Demonstrable skills in written and spoken English sufficient for the full range of duties and responsibilities Evidence of current competency and practical experience in LTC management from appointment
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 South and East Leeds GP Group
Address Hosted Employers address
1st Floor Park Edge Practice
Asket Drive
Leeds
West Yorkshire
LS14 1HX
United Kingdom
Employer's website https://www.seleedsgpgroup.nhs.uk/ (Opens in a new tab)