Advanced Nurse Practitioner (Frailty and Proactive Care)

Clinical Practice Undertake advanced clinical assessment of patients with frailty, complex needs and multiple long-term conditions Provide holistic assessment including physical, psychological, functional and social needs Undertake Comprehensive Geriatric Assessments (CGA) Diagnose and manage acute and chronic conditions within professional competence Independently prescribe medication where qualified and appropriate Develop personalised care and support plans Complete anticipatory care planning and advance care planning discussions Undertake home visits for housebound and vulnerable patients Support care home residents through regular clinical reviews Identify patients at risk of deterioration, admission or crisis and implement preventative interventions Participate in multidisciplinary case management meetings Frailty and Proactive Care Lead the identification of patients living with moderate and severe frailty using risk stratification tools and clinical judgement Support delivery of PCN proactive care and personalised care programmes Develop pathways for frailty management and prevention Support falls prevention initiatives and medication reviews Coordinate care for patients with complex needs and frequent hospital admissions Work collaboratively with community services to reduce avoidable admissions and improve patient outcomes Promote healthy ageing and independence Leadership and Service Development Provide clinical leadership for integrated services across the PCN Support service redesign and quality improvement initiatives Participate in audit, evaluation and service development projects Support implementation of local and national priorities relating to frailty Contribute to workforce development and training of other healthcare professionals Partnership Working Work collaboratively with GPs, Clinical Pharmacists, Social Prescribers, Care Coordinators, Community Nurses, Therapists and Social Care teams Attend multidisciplinary team meetings and neighbourhood team meetings Develop effective relationships with secondary care, community providers, voluntary sector organisations and care homes Support integrated working across organisational boundaries Clinical Governance Maintain accurate and contemporaneous clinical records Work within NMC Code, professional standards and local policies Participate in clinical audit and quality improvement activity Maintain mandatory training and continuing professional development Support safeguarding processes for adults at risk Contribute to incident reporting and learning. Job description Job responsibilities Clinical Practice Undertake advanced clinical assessment of patients with frailty, complex needs and multiple long-term conditions Provide holistic assessment including physical, psychological, functional and social needs Undertake Comprehensive Geriatric Assessments (CGA) Diagnose and manage acute and chronic conditions within professional competence Independently prescribe medication where qualified and appropriate Develop personalised care and support plans Complete anticipatory care planning and advance care planning discussions Undertake home visits for housebound and vulnerable patients Support care home residents through regular clinical reviews Identify patients at risk of deterioration, admission or crisis and implement preventative interventions Participate in multidisciplinary case management meetings Frailty and Proactive Care Lead the identification of patients living with moderate and severe frailty using risk stratification tools and clinical judgement Support delivery of PCN proactive care and personalised care programmes Develop pathways for frailty management and prevention Support falls prevention initiatives and medication reviews Coordinate care for patients with complex needs and frequent hospital admissions Work collaboratively with community services to reduce avoidable admissions and improve patient outcomes Promote healthy ageing and independence Leadership and Service Development Provide clinical leadership for integrated services across the PCN Support service redesign and quality improvement initiatives Participate in audit, evaluation and service development projects Support implementation of local and national priorities relating to frailty Contribute to workforce development and training of other healthcare professionals Partnership Working Work collaboratively with GPs, Clinical Pharmacists, Social Prescribers, Care Coordinators, Community Nurses, Therapists and Social Care teams Attend multidisciplinary team meetings and neighbourhood team meetings Develop effective relationships with secondary care, community providers, voluntary sector organisations and care homes Support integrated working across organisational boundaries Clinical Governance Maintain accurate and contemporaneous clinical records Work within NMC Code, professional standards and local policies Participate in clinical audit and quality improvement activity Maintain mandatory training and continuing professional development Support safeguarding processes for adults at risk Contribute to incident reporting and learning.