About this role
Job summary
The Long-Term Condition (LTC) Home Visiting Service is a proactive, patient-centred initiative supporting housebound patients across the Maltby Wickersley Primary Care Network. Delivered by a highly experienced clinician, the service provides comprehensive, home-based assessments to improve the health and wellbeing of individuals living with chronic conditions.
Working closely with GP practices, the practitioner delivers preventative and anticipatory care to optimise clinical outcomes, reduce avoidable hospital admissions, and ease pressure on practice teams.
Key Components of Each Visit:Holistic Assessment: Reviewing LTCs, monitoring vital signs, and conducting medication reviews.
Wellbeing & Safety: Assessing lifestyle factors, vaccination status, cognition, mobility, and social circumstances.
Future Care Planning: Identifying unmet health and social needs to ensure early intervention.
Through effective multidisciplinary team (MDT) coordination, the clinician partners with care coordinators and healthcare professionals to secure appropriate follow-up and ongoing support.
By delivering high-quality, personalised care at home, this service aims to enhance patient safety, support Quality and Outcomes Framework (QOF) objectives, and promote a joined-up approach to community healthcare. Ultimately, its proactive monitoring helps individuals remain independent, safe, and supported in their own homes for as long as possible.
Main duties of the job Job Description: Long-Term Condition (LTC) Home Visiting Practitioner
The LTC Home Visiting Practitioner provides proactive, preventative, and patient-centred care to housebound patients across the Primary Care Network (PCN). Working with GP practices, you will conduct comprehensive annual reviews in line with Quality and Outcomes Framework (QOF) requirements.
Key Responsibilities:
Assessments: Conduct holistic, home-based clinical assessments. Monitor vital signs, review LTC management, assess medications, update lifestyle data, and identify outstanding vaccinations or investigations.
Holistic Care: Evaluate physical, cognitive, emotional, and social wellbeing. Identify risks (falls, isolation, safeguarding, mobility) and review advance care planning/end-of-life considerations.
Documentation: Review patient records pre-visit. Accurately document findings in SystmOne, complete LTC templates, and ensure correct clinical coding.
MD Teamwork: Liaise with Care Coordinators and the multidisciplinary team to facilitate referrals, follow-ups, and ongoing care plans.
Requirements: Excellent clinical judgement, strong organizational skills, and the ability to work independently. You will play a vital role in improving patient outcomes, reducing hospital admissions, and supporting independent living.
About us
The Community Practitioner Alliance CIC is a Care Quality Commission registered company, working across health and social care to deliver services that improve the health and well being of vulnerable groups and ultimately reduce the use of secondary care service.
We specialise in innovative, integrated health and social care strategies to reduce emergency admissions and deliver more effective care in the community. Our organisation has extensive experience of designing, funding, mobilising and delivering acute visiting services utilising skills of Advanced Practitioners from either Paramedic or Nurse Background. We believe in empowering and investing in people who care for others by developing bespoke educational packages as well as playing an integral part in the development of the carer career pathway.
Job description Job responsibilities Job Description: Very Highly Experienced Clinician Long-Term Condition (LTC) Home VisitingJob Overview
Job Title: Very Highly Experienced Clinician Long-Term Condition (LTC) Home Visiting
Employer: CPA, A Community Interest Company
Location: Maltby Wickersley Primary Care Network (PCN)
Operational Base: Delivering services across participating practices, including Morthen Road Group Practice, Wickersley Health Centre, Manor Field Surgery, Blyth Road Medical Centre, Braithwell Road Surgery, and Queen's Medical Centre
Shift Pattern: 09:30 to 18:30
Core ObjectiveThe primary purpose of this role is to deliver a proactive, preventative, and anticipatory care service as a dedicated, very highly experienced clinician across the Maltby Wickersley PCN. The post-holder will focus on housebound patient lists maintained by individual practices, working to optimise Quality and Outcomes Framework (QOF) performance, prevent avoidable hospital admissions, and alleviate operational pressures on core practice teams.
Key Responsibilities and Operational Workflow1. Care Delivery & Scheduling Conduct comprehensive home visits for eligible patients identified and scheduled directly by individual practices into a centralised booking ledger within the SystmOne Connect Unit.
Manage appointments based on practice-determined eligibility, operating without rigid or restrictive triage criteria at the point of booking.
2. Pre-Visit Clinical Preparation & AuditingPrior to conducting a patient home visit, the clinician is required to perform a comprehensive audit of the patient's records within SystmOne, focusing on the following areas:
Community Service Duplication Check: Screen the clinical tree to ensure the patient is not under active, identical long-term condition monitoring by a Community Matron, District Nursing team, or Specialist Palliative/Hospice team.
Workspace Audit: Review the Activity Indicators on the right-hand panel of the SystmOne workspace to identify outstanding practice-level actions, tasks, and reminders.
Demographic Alert Review: Check status icons beneath the patient's demographic box for targeted alerts, including cholesterol markers, statin compliance, smoking status, or high-risk drug monitoring warnings.
Journal Review: Evaluate the tabbed journal and New Journal (NJ) to identify recent clinical activity such as emergency department attendances, recent hospital discharges, or outstanding issues requiring practice resolution.
QOF Timeline Audit: Access the Ardens LTC template to review the QOF timeline and explicitly identify any red-coded, un-actioned clinical markers for the current fiscal year.
Vaccination Audit: Review immunisation history to identify and administer outstanding seasonal or routine vaccinations, such as Pneumococcal, Influenza, or COVID-19 boosters, on-site during the visit.
3. Clinical Assessment & StandardsDuring the home visit, the clinician must execute high-quality clinical assessments using systematic tools and protocols:
Template Activation: Utilise the Ardens "Briefcase" icon located in the patient status alerts tray at the top-right of the SystmOne screen.
Baseline Physiology & Weight: Measure and record complete baseline vital signs, including blood pressure, pulse, oxygen saturation, and temperature. Weigh the patient where physically safe, or clearly document physical and mobility limitations within the template to preserve QOF data quality.
Lifestyle Risk Factors: Record and update key lifestyle risk factors, including smoking status, alcohol consumption, and nutritional status.
Social & Functional Screening: Screen for social and functional barriers, focusing directly on social isolation, loneliness, carer support, falls, environmental safety hazards, and mobility limitations.
Cognitive Assessment: Review dementia progression and the level of support required, utilising cognitive tools such as the 6-CIT where appropriate.
Condition-Specific Review: Navigate the Ardens template to complete specific QOF indicators, such as respiratory inhaler technique for COPD or sensory foot examinations for diabetes.
Diagnostic & Medication Audits: Verify the dates of the last comprehensive blood panel (including renal function, HbA1c, and thyroid function) and flag for a repeat if older than 12 months. Similarly, verify the last medication review date and flag for a repeat if it occurred more than 12 months ago or is pending soon.
Palliative & End-of-Life Screening: Assess whether the patient is entering a clinical transition phase or approaching the end of life, ensuring they are recorded on the active practice palliative care register and that supportive measures are established.
Advanced Care Planning: Verify the presence of active Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) documents and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) documents, reviewing them as appropriate.
4. Post-Visit Co-ordination & PathwaysThe clinician is responsible for categorising the clinical outcome of each visit into one of two clear operational pathways, ensuring efficient delegation of routine or administrative actions:
No Actions Required (Close Case): If the patient is clinically stable, long-term conditions are optimised, and no further interventions are required, the clinician will complete the consultation notes in SystmOne and select the "LTC annual review completed" (green tick) status to close the annual recall loop.
Actions Required (MDT Task Delegation): If the visit identifies outstanding healthcare, physical, or social needs, the clinician will document the findings and send a structured clinical task within SystmOne to the Practice Care Co-ordinators for tracking, management, and dissemination to the wider multidisciplinary team.
Time Management and Clinical Capacity
Standard Visit Allocation: The standard allocation for an individual home visit is 1 hour.
Administration Built-In: Each day includes two 10-minute admin catch-up slots in the morning and two admin slots in the afternoon, subject to review based on operational experience.
Breaks: Includes one 30-minute lunch break per shift.
Follow-up Capacity: If a comprehensive review cannot be completed within the 1-hour window, a follow-up visit may be arranged, though this should remain a rare exception to preserve clinical capacity
Person Specification
Qualifications Essential
Essential CriteriaTo be considered for the role of Very Highly Experienced Clinician, candidates must meet the following essential requirements:Clinical Experience: Demonstrable history as a highly experienced autonomous clinician capable of delivering complex, independent clinical assessments in a primary care or community setting. System Knowledge: Advanced proficiency and hands-on experience using SystmOne (including the use of Connect Units, Activity Indicators, and clinical tree navigation). Template Familiarity: Proven experience navigating and accurately completing Ardens LTC templates to track and record clinical data. QOF Knowledge: Solid understanding of the Quality and Outcomes Framework (QOF), with the ability to identify, action, and preserve data quality for key clinical indicators. Assessment Skills: Competence in conducting comprehensive holistic assessments, including lifestyle screening, social/functional evaluations, and cognitive reviews (e.g., 6-CIT). Care Planning: Knowledge and experience in managing palliative care reviews and advanced care planning, including DNACPR and ReSPECT documentation. Communication & Collaboration: Excellent communication skills to coordinate care effectively and delegate multi-disciplinary tasks to Practice Care Co-ordinators.
Desirable
Desirable CriteriaWhile not mandatory, candidates who possess the following qualifications and skills will be at a distinct advantage:Independent Prescribing Status: Valid registration as a Non-Medical Prescriber (e.g., Nurse Prescriber, Pharmacist Prescriber) with the relevant professional body (NMC, GPhC, or HCPC), enabling immediate on-site medication optimization and acute clinical interventions during the home visit.Advanced Clinical Qualification: Possession of a masters level module or full qualification in Advanced Clinical Practice, Clinical Assessment Skills, or Minor Illness/Ailments.Community or Primary Care Experience: Previous experience working within a GP practice, Primary Care Network (PCN), or community-based rapid response/district nursing team.Immunisation & Vaccination Training: Up-to-date certification in basic life support and anaphylaxis, with practical experience administering seasonal and routine vaccinations (e.g., Influenza, Pneumococcal, COVID-19 boosters).
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 Community Practitioner Alliance CIC
Address Maltby Wickersley Primary Care Network
8 Blyth Rd
Maltby
Rotherham
South Yorkshire
S66 8JD
United Kingdom
Employer's website https://www.mymedic.network/ (Opens in a new tab)