Job summary
This role will be patient focused, utilising nursing skills to assess frail patients needs, complete appropriate care plans, working across multiple services. A particular focus for this role is ensuring a patient centred approach to all care that enables individuals to achieve their optimum physical, physiological and social wellbeing.
Lead in the care and development of anticipatory and current care planning for identified practice patients from all four practices in the PCN, to include treatment, preventative care, screening, future planning, and patient education in the practices and also in the patients home.
Main duties of the job
Using data from practice clinical systems (EMIS) and tools such as the Electronic Frailty Index, the Whole System Integrated Care dashboard WSIC dashboard to identify elderly and frail patients from the local PCN population who may benefit from a holistic healthcare review.
Hold a defined caseload of patients, either from data identification or on referral from the GP; and carry out a holistic healthcare review either at the one of the PCN practices or in the patients own home.
Complete Universal Care Plan which needs to include a crisis management plan, be flexible and adaptable to the patients needs and expectation of fluctuation in needs
Discussing with the patient (and their carers if appropriate) their views, wishes and help them make decisions about their care options particularly in the future when they may be less well, in hospital or receiving palliative care. (Including DNARs)
Review each patient on the caseload a minimum of 3 monthly/annually (as required/appropriate) and to amend care plans to reflect the patients changing needs.
Motivate patients in respect of self-care and self-management of their condition.
Signpost vulnerable and socially isolated patients to appropriate community services, groups and activities through liaison with the PCN Social Prescribing team.
About us
We are a highly supportive PCN and the practices all work closely within the PCN, understanding the
importance of a good work/life balance with an open-door ethos.
Our PCN consists of four GP practices caring for a population of just under 30,000 patients.
We work together with a range of local providers, including acute trusts, community services, social
care, voluntary sector and patient participation groups, to offer more personalised, co-ordinated
health and social care to our local population.
Job description
Job responsibilities
Discussing with the patient (and their carers if appropriate) their views, wishes and help them make
decisions about their care options particularly in the future when they may be less well, in hospital or receiving palliative care. (Including DNARs)
Review each patient on the caseload a minimum of 3 monthly/annually (as required/appropriate) and to amend care plans to reflect the patients changing needs.
Motivate patients in respect of self-care and self-management of their condition.
Signpost vulnerable and socially isolated patients to appropriate community services, groups and activities through liaison with the PCN Social Prescribing team.
Promote safe independent living and to motivate patients to improve and maintain their well-being.
Demonstrate an understanding of the prevention of abuse of vulnerable adults, recognition of the signs of abuse and procedures to follow in the event of an allegation of abuse.
To participate in multi-disciplinary meetings and team meetings as required to ensure excellent communication and good continuity of care.
To take appropriate action where any safeguarding issues are identified. Refer patients with Complex needs to Complex Patient Management Group (CPMG)
Job description
Job responsibilities
Discussing with the patient (and their carers if appropriate) their views, wishes and help them make
decisions about their care options particularly in the future when they may be less well, in hospital or receiving palliative care. (Including DNARs)
Review each patient on the caseload a minimum of 3 monthly/annually (as required/appropriate) and to amend care plans to reflect the patients changing needs.
Motivate patients in respect of self-care and self-management of their condition.
Signpost vulnerable and socially isolated patients to appropriate community services, groups and activities through liaison with the PCN Social Prescribing team.
Promote safe independent living and to motivate patients to improve and maintain their well-being.
Demonstrate an understanding of the prevention of abuse of vulnerable adults, recognition of the signs of abuse and procedures to follow in the event of an allegation of abuse.
To participate in multi-disciplinary meetings and team meetings as required to ensure excellent communication and good continuity of care.
To take appropriate action where any safeguarding issues are identified. Refer patients with Complex needs to Complex Patient Management Group (CPMG)
Person Specification
Qualifications
Essential
- The post-holder will participate in any training programme implemented by the PCN as part of this employment, such training to include: Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work Mandatory training both clinical and non-clinical The post holder is expected to maintain their own clinical registration if working as a registered professional and complete the requirements of any revalidation. Failure to be registered under their Registration Body (such as the GMC, NMC or General Pharmaceutical Council) will result in dismissal.
Person Specification
Qualifications
Essential
- The post-holder will participate in any training programme implemented by the PCN as part of this employment, such training to include: Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work Mandatory training both clinical and non-clinical The post holder is expected to maintain their own clinical registration if working as a registered professional and complete the requirements of any revalidation. Failure to be registered under their Registration Body (such as the GMC, NMC or General Pharmaceutical Council) will result in dismissal.
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).
Additional information
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).