Integrated Care Model: Brings together professionals from health, social care, and community services including advanced clinical practitioners, district nurses, social workers, home carers, and GPs to form one cohesive team. Home-Based Support: Focuses on delivering care directly in patients homes, reducing the need for GP visits, emergency department attendances, and hospital admission Preventative & Proactive Care: Aims to keep vulnerable individuals safe and well at home, preventing crises and supporting hospital discharge. Clinical Assessment and Management: Conduct autonomous and comprehensive clinical assessments of patients, including history-taking, physical examinations, and ordering and interpreting diagnostic tests. Clinical Decision-Making: Formulate differential diagnoses and clinical management plans for acute, chronic, and complex conditions, working within the scope of advanced nursing practice.
Home Visits: Undertake home visits to patients who are housebound or unable to attend the GP surgery, providing timely and appropriate interventions. Prescribing: Prescribe medications and treatments as an independent non-medical prescriber, in line with national and local protocols. Care Coordination: Work collaboratively with GPs, community nursing teams, allied health professionals, social care, and voluntary sector organisations to deliver joined-up care. Patient Education: Provide health promotion, disease prevention advice, and self-management support tailored to individual patient needs.
Safeguarding: Identify safeguarding concerns and take appropriate actions in accordance with local policies and procedures. Documentation: Maintain accurate and up-to-date clinical records, ensuring information is shared appropriately and confidentially. Quality Improvement: Participate in audit, research, and service development activities to improve patient care and outcomes. Key Relationships GPs and other members of the PCN Community nursing and therapy teams Social care and voluntary sector partners Patients, families, and carers