PCN Practice Nurse

Morley and District Primary Care Network have an exciting opportunity for a registered Nurse to join the Proactive Care Team. We would particularly welcome a Nurse who has special interest in Frailty and Long term condition management.

This is a new role that will help support our Neighbourhood Health care model in Morley, along side our contractual obligations for proactive care in the community.

The suitable candidate should have a passion for making adifference in primary care and enjoy working as part of a multi-disciplinary team across clinical and non clinical services. The post holder will be part of our integrated Proactive care team, working along side Specialised ANP's, Nurses, Pharmacist, care coordinators and Health care support as well as local care partnerships.

No two days will be the same in this role, you will be active in the community and supporting patients in their home and in community venues along side our fantastic team to enable patients to live well and proactively manage their health.

The post holder will focus on proactive frailty management and the provision of preventative health care to the PCN population. You will be completing Comprehensive Geriatric Assessments, and supporting the Frailty Team in anticipatory care planning, prevention of avoidable hospital admissions, and delivery of person-centred care for patients with moderate to severe frailty, helping them remain independent and avoid unnecessary hospital admissions 999 calls or High GP attendance.

As an autonomous practitioner you will work proactively within your scope of practice, undertaking advanced clinical assessments of diagnosis and treatments. You will be responsible forthe care delivered, demonstrating critical thinking and clinical decision-making in the management of your patients. You will work collaboratively within the general practice team to meet the needs of patients, supporting the delivery in accordance with policy and procedures.

Morley and District PCN is a collaborative network, supporting 6 practice's in our locality with approximately 65,000 patients.

We are rapidly developing our multi-disciplinary workforce, embedding ourroles, developing our team that makes a real difference to our patients and our practices.

Clinical practice. frailty and proactive care.

• Assess and evaluate treatment programmes that promote health and well-being
• Undertake Comprehensive Geriatric Assessments (CGA)
• Support anticipatory care planning and advance care planning discussions
• Assess, plan, and evaluate individual treatment plans for patients with a known long-term condition
• Proactively identify, diagnose and manage treatment plans for patients at risk of developing a long-term condition as appropriate
• Work with other health care professionals to diagnose, monitor, manage and treat long-term conditions, including holistic and non-drug-based treatment methods using a management plan, and in line with national and local policies and practice needs
• Prioritise health problems and intervene before appropriately to assist the patient in complex, urgent or emergency situations
• Support patients to adopt health promotion strategies that promote patients to live healthily, and apply principles of self-care
• Recognise, assess and refer patients presenting with mental health needs in accordance with the NSF for Mental Health
• Implement and participate in vaccination and immunisation programmes for adults.
• Support delivery of PCN proactive care and personalised care programmes
• Work collaboratively with community services to reduce avoidable admissions and improve patient outcomes

Communication

• Demonstrate sensitive communication styles to ensure patients are fully informed and consent to treatment
• Communicate with and support patients receiving bad news
• Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating
• Anticipate barriers to communication and take action to improve communication
• Estimate and maintain effective communication with…