Long-Term Home Visiting

Job Summary

The Long-Term Condition (LTC) Home Visiting Service provides a proactive, patient-centred initiative supporting house‑bound patients across the Maltby Wickersley Primary Care Network. The practitioner delivers preventative and anticipatory care to optimise clinical outcomes, reduce avoidable hospital admissions, and ease pressure on practice teams.

The LTC Home Visiting Practitioner conducts holistic, home‑based clinical assessments and supports patients in maintaining independence. Key duties include comprehensive annual reviews in line with Quality and Outcomes Framework (QOF) requirements, multidisciplinary team coordination, and high‑quality documentation.

• Conduct comprehensive home‑based clinical assessments, reviewing LTCs, monitoring vital signs, and performing medication reviews.
• Evaluate physical, cognitive, emotional, and social wellbeing; identify risks such as falls, isolation, safeguarding, and mobility issues.
• Document findings accurately in Systm One, complete LTC templates, and ensure correct clinical coding.
• Coordinate with care coordinators and the multidisciplinary team to facilitate referrals and ongoing care plans.
• Manage pre‑visit clinical preparation, including audits of patient records, vaccination history, and QOF timelines.
• Execute high‑quality clinical assessments using systematic tools and protocols (e.g., Ardens templates, 6‑CIT, ReSPECT documents).
• Post‑visit coordination: determine actions required, delegate tasks to MDT, or close cases when no further interventions are needed.
• Allocate time for a standard 1‑hour visit, with embedded admin slots and a 30‑minute lunch break; manage follow‑up visits only when necessary.

Excellent clinical judgement, strong organisational skills, and the ability to work independently.

• Highly experienced clinician capable of delivering independent complex assessments in primary care or community settings.
• Advanced proficiency in Systm One, including Connect Units, Activity Indicators, and clinical tree navigation.
• Proven experience navigating and completing Ardens LTC templates.
• Solid understanding of QOF and ability to identify, act on, and preserve data quality.
• Competence in conducting holistic assessments, lifestyle screening, social/functional evaluations, and cognitive reviews.
• Knowledge of palliative care reviews and advanced care planning (DNACPR, ReSPECT).
• Excellent communication skills to coordinate care and delegate MDT tasks.

• Valid non‑medical prescriber registration (e.g., Nurse Prescriber, Pharmacist Prescriber) to perform on‑site medication optimisation.
• Masters‑level or full qualification in Advanced Clinical Practice, Clinical Assessment Skills, or Minor Illness/Ailments.
• Experience working within GP practice, PCN, or community‑based teams.
• Up‑to‑date certification in basic life support and anaphylaxis, with experience administering vaccinations.

Applicants will need to submit a Disclosure and Barring Service check under the Rehabilitation of Offenders Act (Exceptions Order) 1975.

Applicants must hold current UK professional registration.