Our PCN Advanced Care Nurse Practitioner has the following key responsibilities in delivering health services to our older frail adults:
* Practice both independently within scope of practice and in partnership with the multidisciplinary team (MDT) under the clinical supervision of a General Practitioner or a community consultant where applicable, ensuring interventions and treatments are undertaken in line with best practice.
* Work as part of the practice and wider multidisciplinary teams to support the delivery of a frailty service, reviewing complex patients and sharing expertise to improve patient care.
* Be an independent prescriber, using prescribing and deprescribing skills to optimise the use of medicines to improve patient outcomes.
* Undertaking home visits for the practice or PCN.
Perform at an advanced level under the core capabilities across the four pillars of Advanced Practice (Health Education England Multi-Professional Framework 2017):
1. Clinical Practice: Undertake clinical assessment of the patient, analysing complex clinical signs, patient history, and investigation to establish a clear care plan, including the generation of anticipatory, escalation, or admission avoidance plans, arranging rescue medicines and ensure the completion of out of hours special messages. Interpret clinical results and act on findings accordingly. Liaise closely with medical, therapy, nursing, pharmacy, social prescribing professionals and PCN care co-ordinators on care plans.
2. Admit and discharge patients from the caseload appropriately, providing accurate and effective clinical handovers across professional boundaries and receiving/making referrals as appropriate.
3. Provide advice and clinical decision making where information is lacking.
4. Provide specialist advice and support to staff, relatives or carers of older adults with the aims of enabling shared decision making, obtaining consent and enhancing the quality of patient care.
5. Communicate effectively with patients, and where appropriate family members and their carers, where applicable, complex and sensitive information regarding their physical health needs, results, findings, and treatment choices.
Agree, set and ensure systems are in place to continuously monitor, review and reset clinical standards of care. That wherever possible clinical practice is research based and in line with nationally recognised best practice, commenting on and creating clinical guidelines and procedures to support this. Maintain accurate and contemporaneous health records appropriate to the consultation or advice given in any practice setting, ensuring accurate completion of all necessary documentation associated with patients healthcare and registration with the practice. Recognises own limitations and effectively seeks appropriate help from a range of multiagency and interprofessional resources in their practices.
Leadership and Management: Lead, develop and evaluate the delivery of a responsive, proactive, patient-focused frailty service across the PCN. Communicate at all levels across organisations ensuring that an effective, person-centred frailty service is delivered and understood. Work collaboratively and in partnership with other health care professionals, providing appropriate leadership, guidance, and supervision to colleagues and assisting in recruitment where required. Be involved in planning and implementing standards of care in the practices or PCN, practice guidelines and to continually evaluate the quality of patient care.
Develop processes, protocols, standards, policies and guidelines for others to use in practice through interpreting and synthesising complex information from a variety of sources. Contribute appropriately to clinical governance activities that relate to own area of practice and patient/client group. Contribute to the management of the service, in collaboration with multidisciplinary team and the PCN board. Develop and sustain appropriate collaborative relationships, partnerships, and networks to influence and improve health outcomes and healthcare delivery systems.
Education: Provide supervision, advice, support and training for the clinical and non-clinical members of the frailty team. Where requested, take an active role in educating and developing members of the wider practice multidisciplinary teams, including students through formal and informal teaching sessions. Identify own continuing professional development needs in line with service needs and maintenance of ongoing capability and competence in practice. Actively seek and participate in peer review of their own practice and participate in annual appraisal, 360 feedback for self, demonstrate ongoing professional development by keeping up to date with national and local developments in specialist area of practice.
Maintain a professional portfolio to demonstrate ongoing professional development and capabilities under the four pillars of advanced practice. Complete the relevant training in order to provide multi-professional clinical practice and CPD supervision to other roles within the frailty team and personalised care roles.
Research: Maintain an up-to-date knowledge in the specialist field, using information to affect change in practice and ensuring the effective dissemination of new knowledge. Able to critically appraise and synthesise the outcomes of relevant research, evaluations and audits and act on this information in collaboration with colleagues to continually develop the service.
Able to review and critically appraise new evidence to ensure that practice is evidence based and in line with current local and national guidance. Identify gaps in evidence or areas of practice requiring development, undertaking audit, implementing change of practice where appropriate and evaluating outcomes. Liaise with PCN research lead(s) to initiate or participate in appropriate local and national clinical trials related to the care of an older, frail adult. Share good practice through creating positive opportunities to network locally, regionally, and nationally, and contribute to the wider development of area of practice through publication and dissemination.
Communicate proactively and effectively with all colleagues across the multidisciplinary team, attending and contributing to meetings as required; Support in the delivery of enhanced services and other service requirements on behalf of the PCN. Ensuring cost-effective use of resources, adherence to personnel policies and the achievement of service targets. Participate in the management of patient complaints when requested to do so and participate in the identification of any necessary learning brought about through incidents and near-miss events. Undertake all mandatory training and induction programmes.
Always maintain a clean, tidy, effective working area.
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