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- Tasks: Deliver personalised care for patients with long-term conditions and support independent living.
- Company: Join Bridgwater Primary Care Network, the largest PCN in Somerset, focused on innovative patient care.
- Benefits: Competitive salary, professional development, and a chance to make a real difference in healthcare.
- Why this job: Be part of a proactive team improving lives and reducing hospital admissions for vulnerable patients.
- Qualifications: NMC Registration and experience in managing long-term conditions like diabetes and respiratory diseases.
- Other info: Dynamic environment with opportunities for career growth and collaboration across multidisciplinary teams.
The predicted salary is between 36000 - 60000 £ per year.
An excellent opportunity has arisen for a Long-term condition nurse or ACP. This role will play a key role in delivering anticipatory, personalised care for patients living with long-term conditions and frailty across community and care home settings. With a clinical background in managing conditions such as diabetes, COPD, heart failure, and multimorbidity, the postholder will reduce avoidable deterioration, support independent living, and improve quality of life through holistic assessment, care coordination, and early intervention. Working within an integrated multidisciplinary team, the nurse will champion continuity, equity, and proactive planning particularly for vulnerable and housebound cohorts. One of the main aims of the proactive care team is to help reduce unplanned hospital admissions and A&E attendances.
As an autonomous practitioner, the successful candidate will ideally be a non-medical prescriber, able to demonstrate critical thinking and decision-making relating to long term conditions. We welcome applications from individuals who enjoy providing outstanding patient care, have a keen interest in being part of a team, striving to improve patient experience and outcomes, with excellent communication and IT skills. We are also happy to consider applications from individuals who are already employed by other NHS organisations and explore secondment opportunities for the right candidate with that organisation.
Main duties of the job
- Identify and stratify patients with moderate to severe frailty using validated tools (e.g. eFI, Rockwood).
- Conduct comprehensive biopsychosocial assessments, including cognition, mobility, nutrition, and social support.
- Apply specialist knowledge in managing long-term conditions, such as Diabetes, Respiratory Disease and/or cardiovascular conditions.
- Develop and review personalised care and support plans in collaboration with patients, families, and MDTs.
- Monitor for early signs of deterioration and intervene to prevent crisis or hospital admission.
- Facilitate advance care planning, DNACPR discussions, and end-of-life care coordination.
- Work closely with care home staff, community matrons, geriatricians, ARRS roles, and social care teams.
- Participate in MDT meetings and contribute to integrated neighbourhood team (INT) working.
- Liaise with voluntary sector partners and social prescribing link workers to address non-clinical needs.
Quality & Improvement
- Maintain accurate, timely documentation in shared care records and contribute to PCN dashboards.
- Use data to identify equity gaps and target interventions for low-uptake or high-risk cohorts.
- Contribute to service evaluation, patient feedback, and continuous improvement initiatives.
- Support education and training for care home staff and carers around frailty and LTC management.
About us
Bridgwater Primary Care Network (PCN) is the largest PCN in Somerset with 9 GP practices, a health & wellbeing hub and a diverse population spread across town and rural locations. As a PCN we are forward-thinking, innovative and driven to deliver the best patient care for our population. This includes health population management, and this role ties in with supporting that and tracking the improvements we can make to patients' lives. The focus of the hub is preventative care and supporting self-care management to the population.
Job responsibilities
- Direct clinical involvement in long term condition/chronic disease management.
- Delivery of nursing care to patients in the practice population.
- Providing advice, support and liaison with other practice staff.
- Management of long term conditions which could include: Frailty, Diabetes, Respiratory - Asthma - COPD.
- Enable individuals with long term conditions and their carers to make informed choices concerning their health and well-being and to organise their own support, assistance and action and promoting self-care.
- Support individuals with long term conditions and their carers to change their behaviour and to reduce the risk of complications.
- Manage programmes of care for patients with acute and chronic disease by planning and evaluating care.
- Work across boundaries and in partnership with primary and secondary care clinicians and social services, coordinating care promoting a multi-disciplinary approach.
- Review prescribed medication and provide advice on all aspects of medicines management, within scope of practice. Refer to relevant clinicians where appropriate.
Confidentiality
The post holder will maintain appropriate confidentiality of information relating to commercially sensitive matters regarding PCN business, and to personal information relating to members of staff and patients. The post holder will be expected to comply with all aspects of the Data Protection Act (1998).
Equality & Diversity
Bridgwater Bay PCN is committed to achieving equality of opportunity for all staff and for those who access services. You must work in accordance with equal opportunity policies/procedures and promote the equality and diversity agenda of the PCN.
Safeguarding
All employees have a duty for safeguarding and promoting the welfare of children and vulnerable adults. Staff must be aware of the procedure for raising concerns about the welfare of anyone with whom they have contact.
Risk Management / Health and Safety
Employees must be aware of the responsibilities placed on them under the Health & Safety at Work Act 1974, ensure that agreed safety procedures are carried out and maintain a safe environment for employees, patients and visitors.
Records Management
The post holder has responsibility for the timely and accurate creation, maintenance and storage of records in accordance with policy, including email documents and regarding the Data Protection Act, The Freedom of Information Act and any other relevant statutory requirements.
Clinical Governance
The post holder will be expected to participate in clinical governance activities to assist the PCN to provide high quality services.
Prevention and Control of Healthcare Associated Infection
The post holder is expected to comply with Infection Control Policies and conduct themselves at all times in such a manner as to minimise the risk of healthcare associated infection.
Policies & Procedures
Employees are expected to follow policies, procedures and guidance as well as professional standards and guidelines.
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Person Specification
- NMC Registration.
- Diplomas in care of patients with Diabetes, asthma / COPD.
- Understanding of proactive care and frailty models, data interpretation for improved patient outcomes.
- Experience of working with patients to achieve goals specific to their health needs.
- Experience in helping patients to manage their long term conditions, specifically Diabetes and respiratory conditions.
- Ability to liaise with the wider multidisciplinary team to help the patient achieve their goals.
- Experience in working in Primary care.
- Experience of EMIS and commonly used IT systems, care home or community experience.
Long Term Conditions Nurse / ACP (Fixed Term) in Bridgwater employer: Bridgwater Bay Primary Care Network
Contact Detail:
Bridgwater Bay Primary Care Network Recruiting Team
StudySmarter Expert Advice 🤫
We think this is how you could land Long Term Conditions Nurse / ACP (Fixed Term) in Bridgwater
✨Tip Number 1
Network like a pro! Reach out to your contacts in the healthcare field, especially those who work with long-term conditions. A friendly chat can lead to insider info about job openings that aren't even advertised yet.
✨Tip Number 2
Prepare for interviews by brushing up on your clinical knowledge and recent advancements in managing long-term conditions. We want you to shine when discussing how you can contribute to patient care and team dynamics!
✨Tip Number 3
Showcase your passion for patient care! During interviews, share specific examples of how you've made a difference in patients' lives. This will help you stand out as someone who truly cares about improving health outcomes.
✨Tip Number 4
Don't forget to apply through our website! It’s the best way to ensure your application gets noticed. Plus, we love seeing candidates who are proactive about their job search!
We think you need these skills to ace Long Term Conditions Nurse / ACP (Fixed Term) in Bridgwater
Some tips for your application 🫡
Tailor Your Application: Make sure to customise your CV and cover letter to highlight your experience with long-term conditions like diabetes and COPD. We want to see how your skills align with the role, so don’t hold back on showcasing your relevant expertise!
Showcase Your Passion: Let us know why you’re excited about this role! Share your enthusiasm for providing outstanding patient care and how you’ve made a difference in previous positions. A little passion goes a long way in making your application stand out.
Be Clear and Concise: When writing your application, keep it clear and to the point. Use straightforward language and avoid jargon unless it’s relevant. We appreciate a well-structured application that’s easy to read and understand.
Apply Through Our Website: Don’t forget to submit your application through our website! It’s the best way for us to receive your details and ensures you’re considered for the role. Plus, it’s super easy to do!
How to prepare for a job interview at Bridgwater Bay Primary Care Network
✨Know Your Long-Term Conditions
Make sure you brush up on your knowledge of long-term conditions like diabetes, COPD, and heart failure. Be ready to discuss how you've managed these conditions in the past and how you can apply that experience to improve patient care.
✨Showcase Your Teamwork Skills
This role involves working closely with a multidisciplinary team, so be prepared to share examples of how you've collaborated with others in previous roles. Highlight your communication skills and how you’ve contributed to team success.
✨Prepare for Scenario Questions
Expect scenario-based questions that assess your critical thinking and decision-making skills. Think about situations where you've had to intervene early to prevent a crisis or manage a patient's care plan effectively.
✨Demonstrate Your Passion for Patient Care
Let your enthusiasm for providing outstanding patient care shine through. Share stories that illustrate your commitment to improving patient outcomes and how you’ve gone above and beyond to support patients and their families.
