PCN Specialist Nurse Practitioner

An exciting opportunity has become available for an enthusiastic and forward-thinking experienced nurse with extended skills to join the First Coastal PCN in a role that will be developed as it progresses. This role will focus heavily on working with our frail and older people. The successful candidate will be joining our Primary Care Community team, working with GPs, Therapy and Nursing Teams, Pharmacist, Care Co-Ordinators, Health and Wellbeing Coaches and Social Prescribing Link Workers.

Main duties of the job

• Assessing and supporting our complex, frail older people, supporting a proactive, patient-centred approach and acute presentations as they arise.
• Supporting our patients and both informal and formal carers to avoid crises and hospital admissions and to stay well in their own home or preferred care setting wherever and whenever possible.
• Support patients with complex health care needs.
• Carrying out assessments predominantly in patients' place of residence.
• To provide clinically effective, person-centred and evidence-based assessment and undertake anticipatory and personalised care planning and intervention to our patients.
• To provide support and share information and care planning with colleagues to support escalation and care/treatment planning.
• Be able to have and develop skills in advance care planning.

Job responsibilities

• Take referrals from as agreed in the standard operating plan.
• Undertake and contribute to ongoing Comprehensive Geriatric Assessment.
• Assess, plan, implement and evaluate treatment plans with an aim to increase independence to prevent or delay the need for care and support.
• Work with patients, carers and informal carers to plan realistic, outcome-focused goals.
• Effectively manage a caseload of patients as part of a multi-disciplinary team (MDT) providing specialist and evidence-based assessment and interventions to patients in both a stable and acute phase of their condition, ensuring the physical, psychosocial, behavioural, perceptual, cognitive, sensory and environmental needs of patients are addressed.
• Utilise specialist knowledge and clinical reasoning to plan and provide clinical interventions in consultation with other colleagues in the MDT and to work in a range of settings as appropriate (e.g. patients' home or other community setting).
• Adopt a patient-centred and sensitive approach to care, collaborating with patients (and/or carers where appropriate) in all aspects of the outcomes of the assessment, planning, intervention, evaluation, reporting.
• Works as part of a multi-disciplinary community team to support patients effectively.
• Using advance communications skills, be able to have advance care planning discussions and facilitate others to be able to start advance care planning conversations.
• Engage with community partners enabling patients to access social activities to enhance their health and well-being, and to ensure effective, safe care.
• Work collaboratively with significant stakeholders.
• Manage your own caseload and contribute to service development through co-production.
• Assist in the quality and activity monitoring systems to support evaluation of the effectiveness of the service.
• Assist in the maintenance and development of the EHCH service for the PCN.
• Attend practice meetings of the member practices if required, as well as Core Group Meetings (Community MDTs etc).
• Prepared to attend further training courses and supervision sessions as required.
• Provide training to the member practices on relevant therapies or interventions if required and as appropriate.
• Develop clinical leadership and collaboratively support the development of assistant/associate nurse practitioners.
• To also contribute to the development and implementation of education packages.
• Plan, implement, review and improve interventions to meet people's identified needs and manage any associated risk.
• To adhere to the NMC code of professional conduct and ethics, plus associated legislation.
• To demonstrate empowering leadership skills within the team and seek opportunities in local and national area as to promote and develop the profession.
• To participate in Clinical Governance activities, including induction, supervision, personal development review, health and safety, risk management and audit.
• To assess carers and families' needs and signpost or refer them to the relevant support.
• To identify and act on safeguarding concerns using current pathways.

As this is a new and evolving role, this is not an exhaustive list of duties and responsibilities, and the post holder may be required to undertake other duties that fall within the grade of the job, in discussion with their line manager. The content of this job description will be reviewed regularly in the light of changing service requirements and any such changes will be discussed with the post holder.

Other Responsibilities

• To support the PCN Clinical Director(s) and Board in setting and realising the vision, mission and business strategy of First Coastal PCN.
• To play a role in the delivery of high-quality primary health care services.
• Maintain a working relationship with local health care providers in order to enable service delivery of mutual benefit and build a network and knowledge of referral routes to and from service providers.
• To establish and maintain effective liaison with stakeholders including health, voluntary, social and education resources, attending relevant meetings as necessary.
• Liaise with the Care Co-Ordinators to refer people and/or introduce them to appropriate organisations locally and nationally where appropriate, e.g. voluntary, statutory (local authority) and local NHS organisations.
• Support the PCN Manager in providing KPI reports for submission as requested.
• Be responsible for the organisation and planning of own workload to meet set deadlines.
• Follow PCN and practice policies and procedures as appropriate.

Person Specification

Experience

• Experience of working in the NHS or related multi-professional setting dealing appropriately with key partner agencies.
• 5 years post registration experience in a relevant clinical setting.
• Experience of working autonomously within a senior position.
• Evidence of professional development.
• Experience of primary care and dealing with complex patients.
• Understanding of neighbourhood and integrated working.

Qualifications

• Relevant professional qualification at post registration level e.g. community specialist practice, older people, LTCs, Palliative Care.
• Evidence of advanced clinical practice and communications skills.
• Ability to make a differential diagnosis.
• Degree level qualification or equivalent experience and knowledge in a health-related subject.
• Evidence of continuous professional development, LTCs, palliative care, physical examination and history taking skills.
• Demonstrate self-awareness and patient management competencies.
• Computer literacy and knowledge of Microsoft applications.
• Management or leadership qualification.

Evidence of Particular - Knowledge - Skills - Aptitudes

• In-depth understanding of the management of long-term / life-limiting conditions and early identification of palliative care needs.
• Knowledge of organisational structures and relationships in health and social care, well-being, social prescribing and third sector.
• Understanding of the wider determinants of health.
• Computer literacy and knowledge of Microsoft applications.
• Full driving license and use of car for work.
• Experience of conducting original research or clinical audit.

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.