Primary Duties and Areas of Responsibility Deliver a high standard of patient care in Care Homes, General Practice and the community, using advanced autonomous clinical skills, and a broad and in-depth theoretical knowledge base to Manage a clinical caseload dealing with patients needs Provide advanced care and case management to patients with multiple complex long-term conditions and frailty Undertake medical and social care assessment to initiate interventions to improve quality of life in the Nursing, Care Home and housebound setting Reduce fragmentation of care. CARE HOMES CLINICAL ROLE The post-holder will Provide a first point of contact within the PCN for Care Home contacts, working closely with our care coordinators. Provide acute and reactive care as part of a multidisciplinary team MDT in Care Homes or as a Domiciliary visit. This shall include assessment, diagnosis, planning, implementation and evaluation of treatment from a physiological, psychological and social perspective. Work with the PCN team to provide a unified approach across the team to care home, housebound and complex patients. Make professionally autonomous decisions for which he/she is accountable. Consider aspects of care including hydration and nutrition support, oral health, mobility, strength and balance, falls prevention, relationship with other services including OOH and secondary care, continence, skin care and mental health including dementia care, Provide clinical support with PCN wide vaccination programmes. Undertake home visits in accordance with the relevant protocols. Support the delivery of anticipatory care and end of life care plans. Assessments will be based on the Comprehensive Geriatric Assessment model to identify health and social care needs proactively. When necessary, to make appropriate clinical diagnoses, working within own sphere of clinical competence, seeking advice and assistance from the patients GP when appropriate. Use advanced communication skills to facilitate future /advance care planning and treatment escalation plans. Demonstrate and utilise advanced problem solving and clinical decision-making skills to respond appropriately to acute health needs. This will address the assessment and management of falls risks, acute and long-term condition, multiple pathology and where appropriate, frailty, dementia, immobility, incontinence, anxiety and social isolation. Provide ongoing care to be delivered as appropriate, referring, signposting and guiding individuals and families to additional/alternative support services including those both within the PCN and to outside agencies. Proactively support individuals thought to be vulnerable or at risk of hospital admission or deterioration in health and well-being, through development of a virtual care and MDT approach that meets the individuals needs through care provision by the right care professional, at the right time, in the right environment. To be an independent advanced practitioner with a critical awareness of knowledge issues in the field and be actively involved with initiation of service policies, protocols and guidelines as well as implementing and evaluating aspects of change in a complex and unpredictable environment. Promote health and well-being through the use of health promotion, health education, screening and therapeutic communication skills. To identify and address the educational needs of patients, families and care home staff and participate in the delivery of educational development as required in collaboration with other professional bodies. Take an active part in achievement of contractual markers including input into COPD, Asthma, Diabetic and Dementia annual reviews and other QOF requirements, performing health checks and reviews. Data entry on EMIS, with understanding of DES requirements. Perform investigatory procedures as needed by patients and those requested by GPs and the wider PCN, including collection of pathological specimens including intravenous blood samples, swabs, etc. Undertake clinical audits. Help develop and set up new patient services and participate in initiatives to improve existing patient service. Contribute to the development of appropriate record keeping and ensure contemporaneous and comprehensive clinical documentation. Recognise and develop opportunities to expand the service and scope of practice related to changes within the healthcare environment, collaborating with other service providers from within primary, secondary, tertiary and voluntary sectors as appropriate. Collaborate with acute care trusts to support the development of appropriate transfer of relevant patient care information at admission and discharge. Demonstrate practice is shaped by professional accountability and responsibility and adheres to all regulations and guidelines within the NMC