Job summary Are you a Registered Nurse with an interest in caring for people living with long term conditions and increasing frailty, to support them to remain living independently at home or a residential care setting, ensuring planned, optimised and co-ordinated health care for them and their families. Poole Central Primary Care Network, provides services on behalf of five GP Practices to the population of central Poole town, Hamworthy, Upton and Lytchett. We are looking to recruit a registered Nurse to our Enhanced Care Team, ideally with previous experience in a community or primary care setting who would like to join our multi-professional Enhanced Care Team, providing both on the day urgent support and proactive planned care and long-term conditions management. As an experienced RGN, the role will be to co-ordinate the clinical case management for frail and complex health patients, who are at risk of further deterioration in health, an avoidable hospital admission or unnecessary length of hospital stay. This role is offered on a part-time/full-time basis and open to a flexible working pattern. You can find out more about the PCN on our website: www.poolecentralpcn.nhs.uk Main duties of the job To work as a member of the Poole Central Primary Care Network Enhanced Care Team to co-ordinate clinical case management for frail and complex patients and those with long term conditions who are at risk of further deterioration in health or an avoidable hospital admission or unnecessary length of hospital stay. To be responsible for a case-load of patients who have either been identified using an agreed case finding tool (Electronic Frailty Index or Rockwood) or whom have been identified by another healthcare professional as frail or as having a long-term condition. As part of a team approach, to be responsible for identifying an individuals principle needs through a holistic, comprehensive assessment, develop care plans and work closely with other members of the MDT and primary care/community care team to support patients in the community. To support preventative care, screening and patient education to enable the patient to manage frailty and long-term condition. To be adaptable and able to work across all aspects of the service, including where needed, supporting the Care Home and Acute home visiting services. About us Poole Central PCN is the second largest PCN in Dorset and one of the first to develop an operational Hub with a central co-ordination team and clinical teams co-located in a dedicated building. The PCN services comprise a multi-professional Enhanced Care Team, responding to the needs of the population who are housebound or living in long term residential care. The ECT comprises ANPs, RNs, HCAs, Paramedics, Specialist Diabetes and Respiratory Nurses and Clinical Pharmacists, working together to optimise clinical outcomes and support people to remain living independently whenever possible and working closely with Practice Teams to ensure effective co-ordinated care. We work collaboratively with partners in health and social care and are currently developing a number of pathways that involve models if integrated working and information systems and digital technology have a key part to play in achieving greater efficiency in how we work. The post-holder will be employed through The Adam Practice (Lead Practice) on behalf of the PCN and details of Terms and Conditions of employment are available on request. Date posted 09 January 2025 Pay scheme Other Salary Depending on experience Based on experience (equivalent to AFC Band 5/6) Contract Permanent Working pattern Full-time, Part-time, Flexible working Reference number A4962-25-0000 Job locations Lifeboat Quay Medical Centre Lifeboat Quay Poole Dorset BH15 1AE Job description Job responsibilities To undertake a holistic full assessment of the physical and psycho-social care needs of complex and frail patients and those with long term conditions, involving carers and relatives. To establish an individuals functional capabilities with regards to frailty, as well as ability to manage other long-term health conditions. To provide cognitive assessment and identification of mental health needs, referring as appropriate. To identify an individuals principle needs and support them in the development of plans to address related issues, supporting self-management where feasible. To develop a person centred, evidence-based holistic health and social care plan in conjunction with medical/other health professionals and social care colleagues. To provide co-ordination of clinical case management for complex and frail patients and those with long term conditions, who are at risk of declining clinical quality of life or avoidable hospital admission. To discuss assessment outcomes with patients, carers, their GPs and other health and social care professionals. To liaise closely with other health and social care professionals to provide community care and support to meet the needs of an individual. To identify social isolation and loneliness, being proactive in sign-posting to relevant resources to empower patients to remain active and engaged within their communities. Work closely with the social prescribing team. Using a high level of communication and interpersonal skills, establish effective working relationships with patients, their families and carers. To recognise and identify a deterioration in an individuals health and act promptly to reduce risk of rapid deterioration or where appropriate avoid hospital admission. Refer onto relevant health professional as required. To educate individuals and carers/relatives to identify early warnings of deterioration in order to facilitate rapid management of complication or crises. To facilitate early discharge, where possible, from hospital for case managed patients by co-ordination of care and services to be delivered within primary care/community. To identify those individuals with more complex health needs and refer for an holistic, multi-dimensional, interdisciplinary assessment with members of the MDT specialising in older peoples health and/or specialising in long term conditions, to include appropriate specialist secondary care expertise. To participate in the MDT meetings, where appropriate identify patients that may require an MDT review. Job description Job responsibilities To undertake a holistic full assessment of the physical and psycho-social care needs of complex and frail patients and those with long term conditions, involving carers and relatives. To establish an individuals functional capabilities with regards to frailty, as well as ability to manage other long-term health conditions. To provide cognitive assessment and identification of mental health needs, referring as appropriate. To identify an individuals principle needs and support them in the development of plans to address related issues, supporting self-management where feasible. To develop a person centred, evidence-based holistic health and social care plan in conjunction with medical/other health professionals and social care colleagues. To provide co-ordination of clinical case management for complex and frail patients and those with long term conditions, who are at risk of declining clinical quality of life or avoidable hospital admission. To discuss assessment outcomes with patients, carers, their GPs and other health and social care professionals. To liaise closely with other health and social care professionals to provide community care and support to meet the needs of an individual. To identify social isolation and loneliness, being proactive in sign-posting to relevant resources to empower patients to remain active and engaged within their communities. Work closely with the social prescribing team. Using a high level of communication and interpersonal skills, establish effective working relationships with patients, their families and carers. To recognise and identify a deterioration in an individuals health and act promptly to reduce risk of rapid deterioration or where appropriate avoid hospital admission. Refer onto relevant health professional as required. To educate individuals and carers/relatives to identify early warnings of deterioration in order to facilitate rapid management of complication or crises. To facilitate early discharge, where possible, from hospital for case managed patients by co-ordination of care and services to be delivered within primary care/community. To identify those individuals with more complex health needs and refer for an holistic, multi-dimensional, interdisciplinary assessment with members of the MDT specialising in older peoples health and/or specialising in long term conditions, to include appropriate specialist secondary care expertise. To participate in the MDT meetings, where appropriate identify patients that may require an MDT review. Person Specification Qualifications Essential Registered Nurse Desirable Mentorship Qualification Post Graduate qualification Experience Essential Previous experience working in primary/community care setting or working in a relevant secondary care role ie. Care of the Elderly Experience of working under own direction Ability to self-motivate, organise and prioritise workload Desirable Experience of supporting service improvement Experience at supporting peers, new learners and mentoring junior colleagues Personal Qualities and Attributes Essential Excellent written skills and a high level of verbal communication skills Demonstrates compassion and understanding of holistic, patient centred care Ability to use own initiative and recognises own scope limitations Demonstrates team player qualities Information Technology Essential Evidence of working with IT systems including Word, Access, Excel Ability to handle sensitive information confidentially, full awareness of data security Other Essential Subject to the provisions of the Equality Act, able to travel using own vehicle on Network business Person Specification Qualifications Essential Registered Nurse Desirable Mentorship Qualification Post Graduate qualification Experience Essential Previous experience working in primary/community care setting or working in a relevant secondary care role ie. Care of the Elderly Experience of working under own direction Ability to self-motivate, organise and prioritise workload Desirable Experience of supporting service improvement Experience at supporting peers, new learners and mentoring junior colleagues Personal Qualities and Attributes Essential Excellent written skills and a high level of verbal communication skills Demonstrates compassion and understanding of holistic, patient centred care Ability to use own initiative and recognises own scope limitations Demonstrates team player qualities Information Technology Essential Evidence of working with IT systems including Word, Access, Excel Ability to handle sensitive information confidentially, full awareness of data security Other Essential Subject to the provisions of the Equality Act, able to travel using own vehicle on Network business 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. UK Registration Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window). Additional information 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. UK Registration Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window). Employer details Employer name The Adam Practice Address Lifeboat Quay Medical Centre Lifeboat Quay Poole Dorset BH15 1AE Employer's website https://www.adampractice.co.uk/ (Opens in a new tab)