About this role
Job summary
WRS Primary Care Network (PCN)
Winchester Rural South Primary Care Network is seeking an experienced, compassionate, and highly motivated Community-Based Proactive Care Nurse to support the delivery of proactive, person-centred care for people living with frailty within our local community.
This is an exciting opportunity to work as part of an integrated neighbourhood team, helping to shape and deliver a proactive model of care that supports people to remain independent, well, and connected to the services they need. The role focuses on identifying individuals who would benefit from early intervention and coordinated support, ensuring care is personalised, preventative, and responsive to what matters most to each person.
We are looking for a nurse who is proactive, adaptable, and passionate about integrated working, with strong clinical assessment skills and a commitment to delivering high-quality, culturally inclusive care. This role offers the opportunity to make a meaningful difference within a forward-thinking Primary Care Network focused on improving outcomes for people living with frailty.
Main duties of the job
The successful candidate will provide proactive, person-centred support to adults living with moderate to severe frailty who are identified as being at high risk of deterioration or avoidable hospital admission. Working within the PCN and wider integrated neighbourhood team, the postholder will use risk stratification and population health data to support proactive case management for a defined patient cohort.
The role involves undertaking holistic frailty assessments, developing and reviewing personalised care plans, coordinating care across health, social care, and voluntary services, and supporting patients and carers to maintain independence and wellbeing within the community. The postholder will work closely with multidisciplinary teams to ensure timely interventions, continuity of care, and reduction in unnecessary urgent care use.
The role also includes supporting equitable access to services for vulnerable and harder-to-reach populations, promoting culturally inclusive care, maintaining accurate clinical documentation, and ensuring care planning reflects what matters most to the individual.
About us
Winchester Rural South Primary Care Network (WRS PCN) is a collaborative partnership of local GP practices working together with community, mental health, social care, and voluntary sector services to deliver high-quality, joined-up healthcare for our population.
Serving a diverse rural and semi-rural community across the Winchester area, WRS PCN is committed to providing proactive, personalised, and accessible care that supports people to live healthier and more independent lives. The network focuses on prevention, early intervention, and integrated working to improve outcomes for patients, particularly those with complex or long-term health needs.
The successful candidate will join a supportive and developing proactive care team consisting of two other Proactive Care Nurses, a Care Coordinator, and a Social Prescriber, working collaboratively to deliver coordinated, person-centred care to patients across the PCN.
Job description Job responsibilities
The Proactive Care Nurse will proactively manage a defined caseload comprising patients identified within the frailest 10% of the population. Through comprehensive assessment, coordinated care planning, and timely intervention, the role focuses on identifying emerging needs early and addressing issues before they escalate.
A key objective of the role is to reduce reliance on urgent and unplanned services, including emergency department attendances, non-elective hospital admissions, and urgent same-day interventions within primary and community care. This will be achieved through proactive case management, effective multidisciplinary collaboration, and continuity of care across health and social care services.
The postholder will coordinate and deliver targeted interventions, ensuring patients receive responsive, joined-up support that promotes stability, wellbeing, independence, and high-quality care within the community.
Key Tasks and Responsibilities
Clinical Care and Assessment
Conduct home visits to undertake comprehensive frailty assessments using the Comprehensive Geriatric Assessment (CGA) framework.
Carry out holistic patient reviews to identify, monitor, and manage complex healthcare needs, including:
social isolation
falls risk
mobility limitations
nutritional concerns
mental health needs
Support the prevention of avoidable deterioration, crisis, and hospital admission through proactive intervention and monitoring.
Provide clinical monitoring and long-term condition management for patients on the caseload, including:
annual blood tests
Quality and Outcomes Framework (QOF) reviews
long-term condition reviews
vaccinations where appropriate
urine sampling
mobile ECG monitoring
Follow relevant clinical policies, protocols, and evidence-based guidelines.
Personalised Care Planning
Develop personalised care plans in partnership with patients and carers, ensuring plans:
reflect outcomes and goals important to the individual
promote independence and wellbeing
include crisis and contingency planning
are reviewed annually or sooner where clinically appropriate
Ensure care plans are shared appropriately with relevant services, with patient consent.
Ensure each patient on the caseload has a named clinician responsible for care coordination and oversight.
Facilitate Advance Care Planning (ACP) and End-of-Life discussions where appropriate, ensuring patients wishes and preferences are documented and respected.
Multidisciplinary Working and Care Coordination
Work collaboratively as part of the Primary Care Network (PCN) multidisciplinary team alongside GPs, Proactive Care Nurses, Care Coordinators, Social Prescribers, community teams, and voluntary sector partners.
Maintain regular communication with GP practices to support care planning, clinical oversight, and continuity of care.
Collaborate closely with community healthcare providers including district nursing, physiotherapy, occupational therapy, intermediate care, falls services, and Older Peoples Mental Health teams.
Participate in regular multidisciplinary team (MDT) and whiteboard meetings to review complex patients and coordinate care delivery.
Delegate patient reviews and ongoing support appropriately within the multidisciplinary team and contribute to service and pathway development.
Liaise with hospital teams during admissions and following discharge to support continuity of care and enhanced post-discharge support.
Holistic and Preventative Support
Take a holistic approach to wellbeing by supporting social prescribing and addressing wider determinants of health.
Link patients and carers with appropriate NHS, social care, community, and voluntary sector services.
Support patients to access Adult Social Care assessments, community resources, and ongoing support services.
Promote equitable access to healthcare services, particularly for vulnerable or harder-to-reach patient groups.
Documentation and Governance
Record all patient consultations, assessments, and interventions accurately using EMIS templates and ensure records remain up to date.
Following assessments, liaise with named GPs to ensure annual medication reviews are completed.
Share relevant information appropriately and in line with information governance and patient consent requirements.
Education and Service Development
Support the learning and development of colleagues and students through supervision, joint visits, and shared learning opportunities.
Contribute to the ongoing development of proactive care pathways and integrated neighbourhood working within the PCN.
This job description outlines the main duties and responsibilities of the role and is not intended to be exhaustive. The postholder may be required to undertake additional duties appropriate to the role following discussion with their line manager.
Person Specification
Experience Essential
Experience working within primary care, community nursing, frailty, elderly care, or long-term condition management Experience of managing patients with complex physical, psychological, and social needs Experience of multidisciplinary team working Experience undertaking holistic patient assessments and developing personalised care plans
Desirable
Experience working within a Primary Care Network (PCN) or integrated neighbourhood team Experience using Comprehensive Geriatric Assessment (CGA) frameworks
Qualifications Essential
Registered Nurse with current NMC registration Evidence of continuing professional development
Desirable
Additional qualification in frailty, community nursing, elderly care, long-term conditions, or palliative care
Knowledge & Skills Essential
Strong clinical assessment and decision-making skills Understanding of frailty, long-term conditions, safeguarding, and person-centred care Ability to coordinate care across multiple services and agencies Excellent communication and interpersonal skills Ability to build effective relationships with patients, carers, and professionals Competent IT skills and ability to maintain accurate electronic clinical records using systems such as EMIS Understanding of confidentiality, consent, and information governance
Desirable
Knowledge of local community and voluntary sector services
Other Requirements Essential
Full UK driving licence and access to a vehicle for work purposes Ability to undertake home visits across the PCN locality
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 Winchester Rural South Primary Care Network
Address Twyford Surgery
Hazeley Road
Twyford
Winchester
Hampshire
SO21 1QY
Employer's website https://www.bishopswalthamsurgery.nhs.uk/ (Opens in a new tab)