This post supports the PCNs commitment to caring patients close to their homes, reducing hospital admissions, improving patient outcomes, and enhancing the overall patient experience within the community setting. The role will consist of a community delivery of healthcare through acute home visits, and engaging proactively with population health as a part of the Team Up initiative. Conduct comprehensive nursing assessments during home visits, identifying patient needs and developing individualised care plans. Deliver holistic nursing care including wound management, medication administration, chronic disease management, and palliative care as appropriate.
Monitor, evaluate, and review care plans, updating as necessary to reflect changing needs and circumstances. Support the prevention of unnecessary hospital admissions and enable timely discharge from hospital settings by providing responsive community-based care. Work collaboratively with GPs, Advanced Nurse Practitioners, social care, allied health professionals, and voluntary services to ensure coordinated care delivery. Educate and empower patients and their families regarding self-management, health promotion, and lifestyle changes.
Maintain accurate, timely, and professional documentation in line with NMC and organisational policies. Identify and escalate safeguarding concerns in accordance with local and national procedures. Participate in regular team meetings, clinical supervision, and continuous professional development activities. Contribute to service development initiatives, audits, and quality improvement projects within the Primary Care Network.