Job description
Long-Term Conditions & Population Health
Provide expert management of residents living with frailty and long-term
conditions. The post-holder will support patients with
o
Frailty
o
Dementia
o
Diabetes
o
Cardiovascular disease
o
Heart failure
o
COPD
o
Asthma
o
Hypertension
o
Chronic kidney disease
o
Mental health conditions
Promote healthy ageing initiatives.
Identify residents requiring proactive
intervention.
Support reduction in health inequalities.
Interprofessional Working & Collaborative Practice
The post-holder will work across organisational and
professional boundaries to improve outcomes for patients. The post-holder will participate
in multidisciplinary team meetings.
Work
collaboratively with
o GPs
o Clinical
Pharmacists
o ACPs
o Practice
Nurses
o Community
Nurses
o Social Care
Teams
o Allied
Health Professionals
Education, Training & Workforce Development
Support the delivery of high-quality, evidence-based care.
Support mentorship of practice staff who may
from time to time shadow the role
Participate in clinical meetings and discussions
Share learning from incidents, audits and
quality activities.
Support development of multidisciplinary team
capability.
Promote evidence-based practice.
Digital & Operational Support
The post-holder will
Maintain
accurate and contemporaneous clinical records.
Ensure
appropriate use of SNOMED coding and clinical templates.
Utilise SystmOne
and associated clinical systems effectively.
Manage
clinical correspondence and test results.
Support call
and recall systems.
Participate
in the use of digital-first models of care where appropriate.
Maintain
information governance compliance.
Contribute
to operational efficiency and service improvement.
Research, Audit & Quality Improvement
The post-holder will
Participate
in clinical audits.
Undertake
data collection and service evaluation.
Analyse care
home activity and outcome data.
Participate
in significant event reviews.
Support
implementation of national guidance.
Contribute
to evidence-based service development.
Evaluate
outcomes and implement improvements.
Job description
Job responsibilities
Long-Term Conditions & Population Health
Provide expert management of residents living with frailty and long-term
conditions. The post-holder will support patients with
o
Frailty
o
Dementia
o
Diabetes
o
Cardiovascular disease
o
Heart failure
o
COPD
o
Asthma
o
Hypertension
o
Chronic kidney disease
o
Mental health conditions
Promote healthy ageing initiatives.
Identify residents requiring proactive
intervention.
Support reduction in health inequalities.
Interprofessional Working & Collaborative Practice
The post-holder will work across organisational and
professional boundaries to improve outcomes for patients. The post-holder will participate
in multidisciplinary team meetings.
Work
collaboratively with
o GPs
o Clinical
Pharmacists
o ACPs
o Practice
Nurses
o Community
Nurses
o Social Care
Teams
o Allied
Health Professionals
Education, Training & Workforce Development
Support the delivery of high-quality, evidence-based care.
Support mentorship of practice staff who may
from time to time shadow the role
Participate in clinical meetings and discussions
Share learning from incidents, audits and
quality activities.
Support development of multidisciplinary team
capability.
Promote evidence-based practice.
Digital & Operational Support
The post-holder will
Maintain
accurate and contemporaneous clinical records.
Ensure
appropriate use of SNOMED coding and clinical templates.
Utilise SystmOne
and associated clinical systems effectively.
Manage
clinical correspondence and test results.
Support call
and recall systems.
Participate
in the use of digital-first models of care where appropriate.
Maintain
information governance compliance.
Contribute
to operational efficiency and service improvement.
Research, Audit & Quality Improvement
The post-holder will
Participate
in clinical audits.
Undertake
data collection and service evaluation.
Analyse care
home activity and outcome data.
Participate
in significant event reviews.
Support
implementation of national guidance.
Contribute
to evidence-based service development.
Evaluate
outcomes and implement improvements.