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.

Knowledge and Skills

Essential

• Advanced clinical assessment and diagnostic skills
• Knowledge of frailty syndromes and management
• Understanding of Comprehensive Geriatric Assessment
• Knowledge of personalised care and anticipatory care planning
• Understanding of safeguarding adults
• Excellent communication and interpersonal skills
• Ability to work independently and manage competing priorities
• Ability to influence and lead change

Experience

Essential

• Significant experience working as an Advanced Nurse Practitioner
• Experience managing people with frailty and multiple long-term conditions
• Experience of autonomous clinical decision making
• Experience undertaking home visits
• Experience of multidisciplinary team working
• Experience of clinical assessment and diagnosis of complex patients

Desirable

• Experience working within Primary Care
• Experience supporting care homes
• Experience of service development and quality improvement
• Experience of Comprehensive Geriatric Assessment

Qualifications

Essential

• Registered Nurse with current NMC registration
• MSc Advanced Clinical Practice or equivalent advanced practice qualification
• Independent Prescribing Qualification
• Evidence of ongoing professional development

Desirable

• Qualification in Frailty, Gerontology or Older Persons Care
• Leadership or management qualification

Personal Attributes

Essential

• Compassionate and patient-centred
• Highly motivated and proactive
• Flexible and adaptable
• Strong team player
• Professional and approachable
• Committed to reducing health inequalities and improving outcomes

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).