Clinical Lead Nurse Diabetes Neigbourhood Health Programme

Clinical Lead Nurse for Diabetes Neigbourhood Health Programme

• The Clinical Lead Nurse for Diabetes is a senior clinical role within the Tier 2 Neighbourhood Support Team. The postholder holds a patient-facing caseload, delivering advanced diabetes nursing care in complex multimorbidity as an autonomous clinician. Responsibilities include insulin and injectable initiation and titration; use of CGM and Flash Glucose Monitoring data for titration; delivery of structured education; joint visits with district nursing for assisted insulin;
  
  contribution to the Tier 2 MDT and weekly Tier 3 MDT (combined with the LTHT community diabetes MDT); joint clinics with Practice Diabetes Leads; TARGET education across Tier 1;
  Advice and Guidance to primary care within 24-hour urgent and one-week routine SLAs; clinical leadership and supervision of nursing colleagues; and active outreach to people in deprivation deciles 1 to 3 and named priority groups. Contribution to service development, quality improvement and equity of diabetes care. Purpose of the role The Clinical Lead Nurse for Diabetes is a senior clinical role within the Tier 2 Neighbourhood Support Team of the Diabetes Neighbourhood Health Programme a new integrated model of care for adults aged 1867 with diabetes (any type) and two or more other long-term conditions, delivered across the Beeston and Middleton & Hunslet PCN footprint and expanding across the Multi-Neighbourhood over the three-year development period.
  
  The role is patient-facing, holds an active caseload within the Tier 2 cohort, and delivers advanced diabetes nursing care across injectable therapy, structured education and complex multimorbidity. The postholder is a core participant in the Tier 2 MDT and the weekly Tier 3 MDT (combined with the existing LTHT community diabetes MDT), provides Advice and Guidance to primary care, leads joint clinics with the Practice Diabetes Lead in each footprint practice, and drives workforce development across Tier 1 and Tier 2 through quarterly TARGET education.
  
  Active outreach and engagement with deprivation deciles 13 and named priority groups (people with learning disability, serious mental illness, those homeless or vulnerably housed, those who smoke or use substances, adults living alone) is a core expectation of the role. The postholder is expected to work in a person-centred, trauma-informed way, with a working understanding of the wider social determinants of health.
  
  Key duties and responsibilities Advanced diabetes nursing and injectable therapy Advanced clinical assessment and consultation with patients on the Tier 2 caseload, including remote and asynchronous consultation. Insulin initiation, titration and ongoing management across all regimens basal, biphasic, basal-bolus including remote support by phone and asynchronous tools. Subcutaneous GLP-1 receptor agonist initiation, titration and ongoing management (oral GLP-1 and GLP-1 / GIP formulations are prescribed at Tier
  1). Use of Continuous Glucose Monitoring (CGM) and Flash Glucose Monitoring data for titration, escalation and shared decision-making. Joint visits with district nursing for patients requiring assisted insulin administration. Delivery of structured diabetes education DAFNE, DESMOND, Confidence with Carbohydrates or equivalent, and pre-conception / pre-pregnancy education where relevant. Non-Medical Prescribing within scope of practice (post-holders holding V300); clear escalation to Tier 2 Pharmacist or Tier 3 Consultant colleagues for complex prescribing decisions.
  
  Recognition of and appropriate response to acute deterioration, including sick-day rules education, hypo unawareness identification and referral to Tier 3 or Tier 4 as required. Care coordination and complex multimorbidity Holding and managing an active caseload within the Tier 2 cohort, with responsibility for planning, delivering and evaluating patient-centred nursing care. Care coordination across the Tier 2 team who holds the patient list, how follow-up cadence is decided, and how patients move safely between tiers.
  
  Contribution to the Tier 2 approach to cardio-renal-metabolic multimorbidity, working…