PCN Cardiometabolic Health Nurse

Note:

it is recognised that candidates are likely to have more advanced training and competencies in some clinical areas than others. The level of clinical responsibility will be adjusted accordingly. The role is a broad one and it is not expected that candidates will have specialist training in all the clinical components

• Undertake comprehensive cardiometabolic assessments for patients identified through risk stratification and population health management tools.
• Deliver nursing interventions (within training and competencies) for patients with:
  Liver disease, Hypertension, Diabetes, Prediabetes, Hyperlipidaemia, Obesity, Chronic kidney disease, Cardiovascular disease.
• Optimise cardiovascular risk factors in line with NICE guidance and local pathways.
• Support medication reviews and treatment optimisation in conjunction with GPs, pharmacists, and prescribing clinicians.
• Undertake and (within training and competencies) act on clinical investigations including blood pressure readings, ECGs, pathology test results
• Develop personalised care plans in partnership with patients and carers, to include a ReSPECT plan, where relevant.
• Ensure close multi-professional and multi-agency working, especially with other members of the local Integrated Neighbourhood Team(s), to facilitate the delivery of each patients PCSP.
• Promote self-management and lifestyle modification through health coaching techniques.
• Refer patients appropriately to community, secondary care, and voluntary sector services.

• Lead proactive case-finding programmes for patients at risk of cardiometabolic disease.
• Support delivery of NHS Health Checks and cardiovascular prevention programmes.
• Identify unwarranted variation in care and work with practices to improve outcomes.
• Use population health data to target interventions for high-risk groups.
• Support initiatives aimed at reducing health inequalities across the PCN population.
• Contribute to screening and prevention campaigns.

• Act as a clinical resource and subject-matter expert for cardiometabolic health.
• Support implementation of national and local cardiovascular disease prevention programmes.
• Participate in the development of clinical pathways and protocols.
• Contribute to quality improvement projects across the PCN.
• Support achievement of Quality and Outcomes Framework (QOF), IIF, and locally commissioned service requirements.
• Assist in evaluating service effectiveness and patient outcomes.

• Work collaboratively with General Practitioners, Practice Nurses, Clinical Pharmacists, Social Prescribing Link Workers, Health and Wellbeing Coaches, Dietitians, Community Services, Secondary Care Specialists.
• Participate in multidisciplinary team meetings and case discussions.
• Provide education and support to practice staff regarding cardiometabolic care.

• Maintain accurate, contemporaneous patient records.
• Ensure compliance with NMC Code, Data Protection legislation, Information Governance standards, Clinical governance requirements.
• Participate in audit, service evaluation, and reporting activities.
• Maintain confidentiality at all times.

• Maintain active NMC registration.
• Participate in clinical supervision, appraisal, and revalidation.
• Maintain continuing professional development relevant to cardiometabolic care.
• Adhere to all organisational policies and procedures.

• Build and maintain effective working relationships with GPs, acute and community hospitals, Adult Social Care, voluntary sector organisations, and other community services to deliver integrated care.

• Ensure seamless transitions of care and continuity through proactive case management and liaison with all relevant stakeholders.

• Participate in MDT meetings, ensuring collaborative care planning and shared decision-making across system partners.

• Support the development of cardiometabolic medicine and skills for other practitioners, carers, and patients.

• Contribute to the design, implementation, and evaluation of frailty pathways and services.

• Identify and manage clinical risks.

• Promote shared decision-making and ensure care aligns with patients values, goals and what matters to them.

• Collect and analyse data to support risk stratification and segmentation of the patient cohort, monitor outcomes and measure impact, support quality improvement and inform commissioning conversations.

See also the G DOC Ltd All Workers Job Description which applies to all G DOC employees.