Chronic Disease Nurse

Job summary

The Chronic Disease Nurse plays a vital role in delivering high-quality, proactive care to patients with long-term conditions, particularly those who are frail, housebound, or living in care homes. This role focuses on the management and prevention of chronic diseases through evidence-based assessments, personalised care planning, and health promotion. Key responsibilities include administering routine vaccinations (including COVID-19), overseeing chronic disease clinics, reviewing medications, supporting safeguarding, and working collaboratively with external services. The nurse ensures accurate clinical documentation, maintains disease registers, and prioritises patient wellbeing through targeted interventions. Additionally, the role supports wider clinical and quality improvement initiatives, such as audits, policy development, and participation in shared learning to enhance patient outcomes and service delivery. Flexibility is essential, as duties may vary depending on workload and staffing needs.

Main duties of the job

Primary ResponsibilitiesDeliver chronic disease management to housebound patients.Deliver routine vaccinations and immunisations (including COVID-19) to housebound and care home patients.Develop, implement, and embed effective care management programmes for frail and housebound patients.Assess patients needs to ensure appropriate healthcare provision, incorporating evidence-based practice.Develop, implement, and embed health promotion and wellbeing programmes.Implement and evaluate individual treatment plans for chronic disease patients that promote health and wellbeing.Identify, manage, and support patients at risk of developing long-term conditions to prevent adverse health outcomes.Review patient medications to enhance compliance.Provide guidance on the use of prescribed and over-the-counter medications, including side effects and dosages.Request pathology services and process pathology results for housebound and care home patients.Oversee the provision of chronic disease clinics, deliver care as necessary, and refer patients to secondary/specialist care when required.Maintain accurate clinical records in accordance with legislation.Ensure effective use of read codes.Ensure appropriate maintenance and use of chronic disease registers.

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