CLINICAL Leads LTC management across the PCN, supporting quality improvement and assurance initiatives. Supports public health and screening programmes including immunisations, vaccinations, and cervical screening, sexual health and blood-borne virus screening. Embeds population health management approaches within general practice, targeting health inequalities and improving access. Work alongside and as part of a multi-disciplinary team (including GP support) within the PCN to consult with patients and their family to undertake assessments of patient need and devise and evaluate LTC care plans, in accordance with clinically based evidence, NICE guidance and the Direct Enhanced Services contract of the Network.
Carry out clinical nursing practice at an experienced practice nurse level using clinical skills, critical judgements, and knowledge to deliver appropriate and safe care within their level of competence. Evaluate and analyse clinical problems using their clinical knowledge, seeking out and applying relevant evidence, interventions, and equipment to make clinical decisions. Deliver clinical care in the context of continual change, challenging environments, different models of care delivery, innovation and rapidly evolving technologies using analysis and their underpinning knowledge. Be responsible for and deliver proactive care in LTCs and multimorbidity, relevant to the Quality Outcomes Framework (QoF), and Local Enhanced Service expectations.
Collaborate with other members of the PCN including doctors, nurses and AHPs, accepting referrals, using clinical reasoning skills to recognise when referral to them for specialist care may be required. Maintain accurate and contemporaneous health records appropriate to the consultation, ensuring accurate completion of all necessary documentation associated with patient health care. Participate in the review of significant and near-miss events. Teach and advise patients and their families on how to manage their condition or support the multi-disciplinary team to do so.
Support patients to adopt health promotion strategies that promote healthy lifestyles and apply principles of self-care. LEADERSHIP Support, mentor and supervise new-to-practice nurses and other healthcare professionals within the PCN. Work collaboratively across the PCN to enhance integration with community, secondary, and social care services. Advise and support on the development and delivery of workstreams and services that enhance the core general practice offer, relating to area of experience, as part of the PCNs strategy, where appropriate.
Communicate proactively and effectively with all colleagues across the multi-disciplinary team, attending and contributing to PCN and practice-level meetings, as required. Work in partnership with other clinical teams to collaborate on improving the quality of health care by responding to local and national policies and initiatives as appropriate. Liaise and work with professionals from community services, community MDTs and specialists to ensure they are delivering effective care to patients requiring this, as needed.