The Population Health Management (PHM) Advanced Nurse Practitioner (ANP) will work across the PCN to support the delivery of the Population Health Management Programme. This programme is focussed on providing more proactive support and case management to people over 65 with mild/moderate frailty, to keep them healthier for longer in their own homes.
This is an exciting time to join the PCNs in the progression and development of the Primary Care Network and this is a pivotal role in delivering a pioneering health improvement programme. The role will involve leading the assessment of patients over 65 with mild to moderate frailty who are suitable for the programme inputting into their care plans. The post holder will also be responsible for supporting leadership of the PHM care coordinator to identify and engage people to intervene early to maintain good health, prevent deterioration and ensure they are able to access services which meet their range of needs. The role will work within the PCN team and across an integrated neighbourhood team of different health and care professionals involved in the care of this group of patients to create care plans. This role involves patient facing care, and the post holder will be responsible for providing support directly to patients and their carers.
Main duties of the job
Provide clinical leadership and supervision to the PHM care coordinator and other staff involved in the delivery of the Oldham South frailty model, particularly for the management of care pathways of patients with complex cases.
Conduct comprehensive geriatric assessments to holistically assess the different needs of patients with mild or moderate frailty and identify those with complex needs and produce accurate and complete records of the patient consultation, consistent with legislation, policies and procedures.
Refer patients to health, care and other wider community-based services as needed for continuation of care where appropriate.
Conduct assessment of patient activation in their own health to support referrals to health coaching where relevant.
Job responsibilities
Develop and implement person-centred shared care plans for patients, in collaboration with patients and through shared care planning with different healthcare professionals including those across primary care, community health services, secondary care, mental health services, social prescribing and social care.
Support continual process improvement for the programme and make iterations in partnership with the Integrated Neighbourhood Team and PCN team as appropriate, including identifying where there may be health inequalities and providing feedback on where engagement could be enhanced; overseeing the quality and effectiveness of the PHM programme and working with the PCN team to use data and feedback to improve processes; exploring the mechanisms to develop new ways of working.
Monitor and evaluate the quality and effectiveness of the PHM programme, using data and feedback to identify areas for improvement and innovation.
Provide education to staff, patients and carers on topics related to frailty, ageing and chronic conditions, as well as proactive management pathways.
Follow up with patients who do not wish to engage to ensure that they are given an opportunity to enrol if they change their minds.
With the care-coordinator, help maintain a log recording the journey of each patient on the PHM programme, including the services they are referred to.
Provide expert advice to patients and their carers by undertaking Clinical Nursing Practice at an advanced level and using expert knowledge and clinical skills to deliver holistic care.
Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating.
Evaluate patients response to health care provision and effectiveness of care.
Use technology and appropriate software e.g., EMIS and the Manchester Shared Care Record as an aid to management in planning, implementation and monitoring of care, presenting and communicating information.
Person Specification
Experience
* Advanced clinical practice skills
* Recent primary and community nursing experience
* Nurse-led triage
* Management of patients with long-term conditions and complex needs
* Clinical examination skills
* Experience of administrative duties
* Working in a multi-disciplinary setting
* Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality
* Experience in use of databases
* Knowledge of public health issues
* Project management
Skills
* Clinical leadership skills
* Change management
* Flexible approach and highly motivated.
* Evidence of excellent knowledge of using NHS IT systems such as EMIS.
Qualifications
* Experience within Primary Care.
* Registered first level nurse MSc or equivalent
* Experience as an Advanced Nurse Practitioner
* Clinical supervision training and experience
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.
£43,742 to £45,996 a year depending on experience.
#J-18808-Ljbffr