Nurse Practitioner / Advanced Care Practitioner

As a Practitioner working within the Community Care Team, you will provide care for patients identified as vulnerable and those with complex physical and/or mental health needs, who are at high risk of hospital admission or readmission, with a focus on reducing avoidable unplanned admissions. The role involves home visits to housebound patients, including those in nursing and residential homes, as well as palliative care patients. There will also be opportunities to see patients at the practice and support chronic disease management for our most vulnerable patients.

As well as working closely with all clinicians across the practice to support these patients, the team maintains excellent partnerships with wider healthcare teams and holds regular multidisciplinary team (MDT) meetings. You will therefore also work closely with district nurses, hospice/palliative care nurses, health connectors, the hospital discharge liaison team.

Main duties of the job

• Undertake shared decision-making with CCT patients and their carers to ensure holistic care that focuses on what matters most to patients.
• Work to deliver patient-centred care aimed at preventing hospitalisation, including end-of-life and complex cases, with early intervention for frailty and vulnerability.
• Act as lead clinician for designated care homes, including undertaking weekly ward rounds.
• Respond to patients medical problems, including history-taking, examination, investigation, diagnosis, treatment, and referral when appropriate.
• Produce and maintain accurate and detailed patient records.
• Provide care to patients in their homes and in care homes, working independently.
• Support the wider practice in delivering care, including urgent care duties when appropriate.
• Manage palliative care, end-of-life processes, complex comorbidities, and chronic conditions.
• Collaborate to review and proactively contact patients recently discharged from hospital, including aligning medications and planning ongoing care.
• Identify and signpost support services for patients and their carers.
• Develop, maintain, and promote links with primary and secondary care teams.
• Attend MDT and team meetings, taking a leadership role as required.
• Implement proactive case management for all patients.
• Participate in clinical governance, audit programmes, and quality improvement initiatives.
• Maintain clinical competence and performance through ongoing educational activity.

About us

FromeMedical Practice is a single site Practice and Primary Care Network with 30,000patients who live in the attractive market town of Frome and its surroundingvillages. We are a recognised Learning Organisation with a strong focus onClinical education and development, including being a GP Training Practice forRegistrars. Frome Medical Practice isbased in a fantastic purpose built centre with excellent facilities and a largesupportive team. Staff wellbeing is astrong focus and we have an active social committee.

Weare co-located with district nurses, an independentpharmacy and cafe all on the premises and our local community hospital is nextdoor. This all supports our active approach to multidisciplinary working.

We are National award winners for our worktowards Green Impact initiatives.

We are one of 21 PCNs who have been acceptedonto the PCN Pilot Programme working with NHSE.

Job responsibilities

Undertake shareddecision making with our complex care patients and their carers, to ensure thatcare delivered is holistic and focuses on what matters most to patients.

Working as part of a teamand autonomously to promote individualised patient-centred care to preventhospitalisation, including end-of-life and complex cases with earlyintervention for frailty and vulnerability.

Responding to medicalproblems presented by patients, including history taking, examination,investigation, diagnosis, treatment, and referral where appropriate.

Produce and maintainaccurate and detailed patient notes.

Provide care to patientsin their homes, as well as in care homes.

To be a lead clinicianfor designated care homes and undertake weekly ward rounds.

To support the widerpractice delivery of care, including supporting urgent care on duty whenappropriate.

Management of palliativecare, end-of-life processes, complex comorbidities, and chronic conditions.

Working within the teamto review and proactively contact those recently discharged from hospital,including alignment of medications and proactive onward care planning.

Proactively identify andsignpost support, for patients and their carers.

Develop, maintain, andpromote links with primary and secondary care.

Attend MDT/ teammeetings and lead as necessary.

Implement proactive casemanagement for all patients.

Participate in clinicalgovernance and audit programmes.

Maintain clinical competenceand performance through educational activity.

Person Specification Experience

• Advanced post registration experience in a health care setting
• Evidence of appropriate continuing professional development
• Experience working in primary care setting with evidence of appropriate knowledge base
• Experience in managing complex chronic disease
• Experience managing a caseload, complete assessments, plan interventions, implement, and evaluate outcomes according to care plans.
• Ability to co-ordinate and prioritise workloads able to multi-task as well as be self-disciplined and highly motivated
• Demonstrates a flexible approach in order to ensure patient care is delivered
• Ability to work both independently and as part of a team

Qualifications

• Professional Registration with the relevent clinical qualification (e.g. BSc Hons)
• Membership of a professional body e.g., RCN or HCPC
• Independent Prescriber or commitment to work towards this on acceptance of the role
• PACR qualification or equivalent

Other

• Full UK driving licence

Skills & knowledge

• Excellent interpersonal and communication skills

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.