Long Term Conditions Nurse / ACP (Fixed Term)
An excellentopportunity has arisen for a Long-term condition nurse or ACP.
This role will play a key role in delivering anticipatory, personalised care for patients living with long-term conditions and frailty across community and care home settings. With a clinical background in managing conditions such as diabetes, COPD, heart failure, and multimorbidity, the postholder will reduce avoidable deterioration, support independent living, and improve quality of life through holistic assessment, care coordination, and early intervention. Working within an integrated multidisciplinary team, the nurse will champion continuity, equity, and proactive planning particularly for vulnerable and housebound cohorts.
One of the main aims of the proactive care team is to help reduce unplanned hospital admissions and A&E attendances.
As anautonomous practitioner, the successful candidate will ideally be a non-medicalprescriber, able to demonstrate critical thinking and decision-making relatingto long term conditions.
We welcomeapplications from individuals who enjoy providing outstanding patient care, have a keen interest in beingpart of a team, striving to improve patient experience and outcomes, withexcellent communication and IT skills.
We are also happy to consider applications from individuals who are already employed by other NHS organisations and explore secondment opportunities for the right candidate with that organisation.
Main duties of the job
Clinical Practice
* Identify and stratify patients with moderate to severe frailty using validated tools (e.g. eFI, Rockwood)
* Conduct comprehensive biopsychosocial assessments, including cognition, mobility, nutrition, and social support
* Apply specialist knowledge in managing long-term conditions, such as Diabetes, Respiratory Disease and/or cardiovascular conditions.
* Develop and review personalised care and support plans in collaboration with patients, families, and MDTs
* Monitor for early signs of deterioration and intervene to prevent crisis or hospital admission
* Facilitate advance care planning, DNACPR discussions, and end-of-life care coordination
* Work closely with care home staff, community matrons, geriatricians, ARRS roles, and social care teams
* Participate in MDT meetings and contribute to integrated neighbourhood team (INT) working
* Liaise with voluntary sector partners and social prescribing link workers to address non-clinical needs
Quality & Improvement
* Maintain accurate, timely documentation in shared care records and contribute to PCN dashboards
* Use data to identify equity gaps and target interventions for low-uptake or high-risk cohorts
* Contribute to service evaluation, patient feedback, and continuous improvement initiatives
* Support education and training for care home staff and carers around frailty and LTC management
About us
Bridgwater Primary Care Network (PCN) is the largest PCN in Somersetwith 9 GP practices, a health & wellbeing hub and a diverse populationspread across town and rural locations.
As a PCN we are forwardthinking, innovate and driven to deliver the best patient care for ourpopulation. This includes health population management, and this role ties inwith supporting that and tracking the improvements we can make to patientslives.
The focus of the hub ispreventative care and supporting self-care management to the population.
Job responsibilities
Main dutiesof the job
Job Summary
Direct clinical involvement in long termcondition/chronic disease management
Delivery of nursing care to patients in thepractice population
Providing advice, support and liaison with otherpractice staff
Jobdescription
Managementof long term conditions which could include:
Frailty
Diabetes
Respiratory
- Asthma
- COPD
Enable individuals with long term conditions and their carers to makeinformed choices concerning their health and well being and to organise theirown support, assistance and action and promoting self care
Support individuals with long term conditions and their carers to changetheir behaviour and to reduce the risk of complications
Manage programmes of care for patients with acute and chronic disease byplanning and evaluating care
Work across boundaries and in partnership with primary and secondary careclinicians and social services, coordinating care promoting amulti-disciplinary approach.
Review prescribed medication and provide advice on all aspects ofmedicines management, within scope of practice. Refer to relevant clinicianswhere appropriate.
Confidentiality The post holder will maintainappropriate confidentiality of information relating to commercially sensitivematters regarding PCN business, and to personal information relating to membersof staff and patients. The post holderwill be expected to comply with all aspects of the Data Protection Act (1998).
Equality& DiversityBridgwater Bay PCN is committedto achieving equality of opportunity for all staff and for those who accessservices. You must work in accordance with equal opportunitypolicies/procedures and promote the equality and diversity agenda of the PCN.
SafeguardingAll employees have a duty forsafeguarding and promoting the welfare of children and vulnerable adults. Staffmust be aware of the procedure for raising concerns about the welfare of anyonewith whom they have contact.
Risk Management /Health and SafetyEmployees must be aware of the responsibilitiesplaced on them under the Health & Safety at Work Act 1974, ensure thatagreed safety procedures are carried out and maintain a safe environment for employees, patients and visitors.
RecordsManagement The post holder hasresponsibility for the timely and accurate creation, maintenance and storage ofrecords in accordance with policy, including email documents and regarding theData Protection Act, The Freedom of Information Act and any other relevant statutoryrequirements.
ClinicalGovernance The post holder will be expected to participatein clinical governance activities to assist the PCN to provide high qualityservices.
Prevention and Control ofHealthcare Associated Infection The post holder is expected tocomply with Infection Control Policies and conduct themselves at all times insuch a manner as to minimise the risk of healthcare associated infection.
Policies& Procedures Employees are expected to followpolicies, procedures and guidance as well as professional standards andguidelines.
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (ExceptionsOrder) 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 checkfor any previous criminal convictions.
Person Specification
Qualifications
* NMC Registration
* Diplomas in care of patients with Diabetes, asthma / copd
Knowledge and Communication
* - understanding of proactive care and frailty models
* data interpretation for improved patient outcomes.
Experience
* Experience of working with patients to achieve goals specific to their health needs.
* Experience in helping patients to manage their long term conditions, specifically Diabetes and respiratory conditions
* Ability to liaise with the wider multidisciplinary team to help the patient achieve their goals.
* Experience in working in Primary care.
* Experience of EMIS and commonly used IT systems
* care home or community experience
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.
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