Care Home Advanced Clinical Practitioner

Advanced Clinical Practice & Acute Response

Acute Visiting Expectations: Act as the lead ACP for urgent and same-day care home assessments, independently managing deteriorating residents and complex undifferentiated presentations. Undertake advanced clinical assessment of frailty syndromes, falls, delirium, respiratory illness, cardiovascular symptoms, infection, end of life care needs and exacerbations of long-term conditions. Provide autonomous clinical decision making, including prescribing, requesting and interpreting investigations, treatment planning and admission avoidance decisions. Main aspect of the role will be to support the practices and visit patients in Care Homes following agreed pathways with the GP Practices. Provide rapid, autonomous assessment of acutely unwell care home residents, utilising advanced physical assessment and clinical history-taking skills as directed by the patients GP practice.

Autonomous Decision Making: Diagnose, formulate, and execute immediate treatment plans for patients presenting with complex, undifferentiated, or unstable conditions.

Prescribing & Medicine Management: Safely prescribe medications within individual scope of practice as an Independent Prescriber or work under Patient Group Directions (PGDs) where applicable, ensuring rigorous adherence to safety standards.

Admission Avoidance: Utilise expert clinical judgment to safely manage high-risk patients in their place of residence, coordinating with community assets to minimize unnecessary hospital admissions. Work across boundaries and in partnership with primary and secondary care clinicians and social services, coordinating care promoting a multi-disciplinary approach. To act as a point of contact, where appropriate for the care home staff when there is a request to see, treat or refer any patient whose health status has deteriorated. To refer patients to the GP practice where appropriate. Act as a specialist clinical resource for care home staff regarding assessment, escalation and management of deteriorating residents. Maintain accurate, timely and legally compliant clinical records using PCN and practice clinical systems. Assess patient needs through effective planning, implement and evaluate care according to individualised patient needs. Ensure that all patient computer records are maintained correctly. Recognise when patient presentation requires referral onto other health professional or specialist teams and take appropriate actions.

Proactive Care & Care Home Team Integration

• Proactive Holistic Reviews: The role will predominantly work on the acute response but will be expected to also provide pro-active Care as part of the function such as participate in scheduled Multi-Disciplinary Team (MDT) reviews as required for care home residents to optimise health, manage frailty, and prevent future health deterioration. The postholder will be required to work closely with practices to manage patients care.
• Personalised Care Planning: To develop individualised care management plans (PCSP for the patients in close discussion with them and their careers, care home staff and GPs.
• Anticipatory Care & DNACPR: Initiate and facilitate sensitive, expert discussions regarding Advance Care Planning (ACP) forms with residents, families, and staff.

Workforce Flexibility: Dynamically pivot daily priorities between urgent acute requests and scheduled proactive reviews based on the immediate clinical demand of the PCN care home population. The post holder will provide support for patients to remain in their own care setting, improving their health outcomes and quality of life. The role will provide clinical skills to patients and provide expert knowledge. The role will support patients with end-of-life support, enabling them to die in their own care home if that is their wish. Supporting the management of residents with multiple long-term conditions, dementia and complex health needs. Lead multidisciplinary discussions for high-risk residents and coordinate rapid responses across organisational boundaries.

Leadership, Governance, & Service Development

• Clinical Leadership: Provide professional and clinical leadership for the Care Home Service across the PCN, acting as an expert resource, role model and senior decision maker for complex patient care.
• Quality Improvement (QI): Identify, design, and implement clinical audits and QI projects to enhance the quality, safety, and efficiency of care home services across the PCN.
• Risk Management: Support any investigation that may occur such as clinical incidents, near-misses, and safeguarding concerns within care homes, ensuring lessons are learned and embedded into local practice.
• Communicate sensitive/contentious and occasionally highly complex medicine related information and advice to patients, carers, GPs and other members of the health care team. Communicate on a variety of different levels depending on whether you are dealing with health professionals or patients. Information may be complex and require translation into a more patient friendly format.
• Leadership and Service Development: Lead development of care home pathways, protocols and standard operating procedures aligned to PCN priorities. To be aware of the Data Protection Act to ensure appropriate action is taken to ensure patient confidentiality and protection of patient information.

Education: Act as a clinical supervisor, mentor and educator for trainee ACPs, nurses, paramedics, physician associates and other healthcare professionals. Deliver education, training and competency development programmes for care home staff and multidisciplinary colleagues. Support the development of advanced clinical skills within the workforce through coaching, supervision and reflective practice. Contribute to induction programmes and ongoing professional development initiatives across the PCN. Promote a culture of lifelong learning and evidence-based practice within care homes and primary care services. Participate in appraisal, competency assessment and professional development activities for staff where appropriate.

Research, Audit and Quality Improvement: Critically evaluate and apply emerging evidence, national guidance and best practice to improve patient care and clinical outcomes. Lead and participate in clinical audit, quality improvement programmes and service evaluations across the Care Home Service. Analyse service data and patient outcomes to identify opportunities for service improvement and innovation. Support implementation and evaluation of new models of care for frail and elderly populations. Disseminate findings from audits, quality improvement projects and research activities to clinical teams and stakeholders. Contribute to local, regional and national ACP, frailty and care home networks, sharing learning and best practice. Participate in and support research activity where appropriate to advance care for older adults and care home residents.