Proactive Care Nurse

Job description

Job responsibilities

The post holder will work closely with the PCN Frailty GP Lead, General Practitioners at all Practices across the A31 Primary Care Network and the wider multi-disciplinary team (MDT) to provide a comprehensive frailty service;.

To support patients requiring enhanced primary care services whilst providing appropriate information, advice or referrals in accordance with agreed protocols.

To take a leadership role in a small team of primary care health professionals delivering care and support to frail patients living independently with a view to preventing hospital admission.

To work collaboratively with the practice teams to ensure the delivery of safe and effective care to the GP Practice population, including treatment, preventative care, screening and patient education.

To support the management team in the reviewing of clinical policy and procedure.

Primary responsibilities

The following are the core responsibilities of the Proactive Care Nurse. There may, on occasion, be a requirement to carry out other tasks; this will be dependent upon factors such as workload and staffing levels:

a. To evaluate and prioritise patients’ symptoms and provide general advice and reassurance in line with the Standards for Better Health and latest clinical research guidelines.

b. Provide assessment, screening and treatment services and health education advice to our frail patients who are in one or multiple frailty categories and who have been referred to your caseload including; house bound patients, severely frail patients, palliative care patients, dementia patients.

c. To provide appropriate signposting to the relevant clinician or external organisation whilst ensuring that the patient receives appropriate ongoing care

d. To promote high standards of patient care by the application of a systematic triage approach and undertake comprehensive holistic assessments of person centred care needs

e. To visit patients at home as part of the wider clinical team

f. To maintain clear, concise and accurate documentation within the systems provided

g. To ensure that all necessary arrangements are completed promptly and in a safe manner

h. To maintain effective communication with multidisciplinary teams to the benefit of the patient and join the weekly Community MDT meetings

i. To maintain the confidentiality of matters relating to patients and patient care in accordance with the NMC guidelines

j. To communicate complex and sensitive information concerning a patient’s medical condition effectively to patients/carers, recognising that sometimes there are barriers to understanding

k. To foster good public relations by ensuring courtesy and discretion when dealing with patients and their relatives

l. To support and advise patients on the promotion of health, prevention of ill-health and the self management of their health within their limitations

m. To recognise situations that may be detrimental to the health and well-being of the individual and act on the findings

n. To ensure that care given is supported by the best available evidence and local policies and procedures

o. To deliver opportunistic health promotion where appropriate

p. Provide nursing treatments to patients in collaboration with GPs or independently to agreed practice protocols.

q. Provide general and specific health screenings to the patients (within agreed protocols) with referral to GPs as necessary.

r. Advise patients on general health care and minor ailments with referral to GPs as necessary.

s. To understand practice and local policies for substance abuse and addictive behaviour, referring patients appropriately

t. To provide leadership within the PCN Proactive Care Team to; a) meet the requirements of the local Proactive Care Service specification; and, b) work with individuals in the team to support their personal development.

u. To uphold the confidentiality of all records/information held by member practices of the A31 Primary Care Network. This duty lasts indefinitely and will continue after you leave your employment at this practice. All information which identifies individuals in whatever form should be managed locally with the Confidentiality Policy and in general in accordance with the Data Protection Act 2018

v. To maintain professional competency whilst remaining current and in date for NMC revalidation

Key Clinical Areas:

· Frailty ICT in conjunction with GPs.

· Preparation of acute prescriptions for caseload.

· Health promotion and individual care plans (including Respect forms) for patients with/at risk of long term conditions.

· Proactively manage and treat long term conditions, in line with national/local and practice policy/ protocols.

· Follow agreed clinical protocols with referral to GPs as appropriate

· Completion of home visits to patients on the frailty case load

Secondary responsibilities

In addition to the primary responsibilities, the frailty nurse may be requested to:

a. Support the wider Community Frailty Team providing guidance when necessary

b. Particpate in audit work, effectively utilising the audit cycle

c. Participate in local initiatives to enhance service delivery and patient care

d. Support and participate in shared learning within the PCN

e. Continually review clinical practices, responding to national policies and initiatives where appropriate

f. Participate in the review of significant and near-miss events applying a structured approach, i.e. root cause analysis (RCA)

Person Specification

Qualifications

Essential

• Registered nurse

Desirable

• Post graduate diploma or degree (primary care)
• Independent prescriber

Experience

Essential

• Experience of working in a primary care environment
• Experience of chronic disease management

Desirable

• Experience of working as a practice nurse or community nurse

Other requirements

Essential

• Flexibility to work outside of core office hours
• Disclosure Barring Service (DBS) check
• Occupational health clearance
• NMC registration
• Access to own transport and ability to travel across the PCN on a regular basis

Personal qualities

Essential

• Polite and confident
• Flexible and cooperative
• Motivated, forward thinker
• Problem solver with the ability to process information accurately and effectively, interpreting data as required
• High levels of integrity and loyalty
• Sensitive and empathetic in distressing situations
• Ability to work under pressure/in stressful situations
• Effectively able to communicate and understand the needs of the patient
• Commitment to ongoing professional development
• Effectively utilise resources
• Punctual and committed to supporting the team effort

Clinical knowledge and skills

Essential

• Venepuncture
• Chaperone procedure
• Requesting pathology tests, processing the results, advising patients accordingly
• Understand the importance of evidence based practice
• Broad knowledge of clinical governance
• Ability to record accurate clinical notes
• Ability to work within own scope of practice and understand when to refer to GPs
• Knowledge of health promotion strategies
• Understand the requirement for PGDs and associated policy

Desirable

• Wound care/removal of sutures and staples
• ECGs
• Diabetes
• Hypertension
• Asthma
• Spirometry
• CHD
• Immunisations (routine, childhood and travel)
• Womens health (cervical cytology, contraception, etc.)
• Knowledge of public health issues in the local area
• Awareness of issues within the wider health arena

Skills

Essential

• Excellent communication skills (written and oral)
• Strong IT skills
• Clear, polite telephone manner
• Competent in the use of Office and Outlook
• Effective time management (planning and organising)
• Ability to work as a team member and autonomously
• Good interpersonal skills
• Problem solving and analytical skills
• Ability to follow clinical policy and procedure

Desirable

• EMIS user skills
• Experience with audits and able to lead audit programmes
• Experience with clinical risk management

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

A31 Primary Care Network

Address

Alton Health Centre

Anstey Road

Alton

Hampshire

GU34 2QX

Employer's website

https://www.wilsonpractice.co.uk/ (Opens in a new tab)