Long Term Nurse​/Acp

Job summary

An excellent opportunity has arisen for a Long-term condition nurse or ACP.

This role will play a key role in delivering anticipatory, personalized 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 an autonomous practitioner, the successful candidate will ideally be a non-medical prescriber, able to demonstrate critical thinking and decision-making relating to long term conditions.

We welcome applications from individuals who enjoy providing outstanding patient care, have a keen interest in being part of a team, striving to improve patient experience and outcomes, with excellent 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 organization.

• 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

• 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

Bridgwater Primary Care Network (PCN) is the largest PCN in Somerset with 9 GP practices, a health & wellbeing hub and a diverse population spread across town and rural locations.

As a PCN we are forward thinking, innovate and driven to deliver the best patient care for our population. This includes health population management, and this role ties in with supporting that and tracking the improvements we can make to patients lives.

The focus of the hub is preventative care and supporting self-care management to the population.

Direct clinical involvement in long term condition/chronic disease management

Delivery of nursing care to patients in the practice population

Providing advice, support and liaison with other practice staff

• Frailty
• Diabetes
• Respiratory
• - Asthma
• - COPD

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