Advanced Clinical Practitioner - Care Home Team

Job responsibilities

This role will undertake the following duties and responsibilities

• Undertake scheduled weekly care home rounds with our aligned care homes.
• Work collaboratively with the rest of the care home team and the practice to ensure that any actions resulting from the weekly ward rounds are completed in a timely manner.
• Work collaboratively with the rest of the care home team and the practices to ensure that all aspects of the EHCH are met.
• Act as a main clinical contact and resource for practice staff in relation to care home patients.
• Undertake necessary discussions with patients, their families and the care home staff with regards to admission avoidance and advance care planning.
• Undertake capacity assessments and act appropriately with regards to the patient's ability.
• Undertaken chronic disease reviews and support the management of these conditions.
• Deliver a service towards proactive care that is centred on the needs of individual residents, their families and care home staff.
• Deliver care according to NSF, NICE guidelines, and evidence-based care.
• Support Care Home staff to maximum better patient outcomes, experience and use of resources.
• Understand and implement the principles of the EHCH model (personalised care, coproduction, collaboration, quality, leadership and digital means).
• Support staff development across the team to maximize potential.
• Provide an educational role to patients, carers, families, and colleagues in an environment that facilitates learning

Clinical Practice Expectations

• Work as an autonomous clinician across all areas to develop and provide expert clinical advice, support and care for care home residents.

• Develop and use advanced clinical skills to analyse and interpret history of illness, presenting symptoms and physical findings to enable diagnosis, planning and treatments of patients.
• Recognise the early symptoms of disease exacerbation and acute illness based on an understanding of disease, the disease process, and current evidence and practice standards.
• Interpret history of illness, presenting symptoms and physical findings to enable diagnosis, planning and treatment of patients.
• Clinically examine and assess patient needs from a physiological and psychological perspective and plan clinical care accordingly.
• Diagnose and manage both acute and chronic conditions, integrating both drug and non-drug-based treatment methods into patient treatment plans.
• Act as lead specialist and a resource to all staff in the delivery of clinical care to patients both inside the Care Home and back at Practice.
• Prioritise and co-ordinate the multiple health care needs of the patient, co-ordinating and facilitating timely referrals to other team members within acute and primary care settings.
• Facilitate the integration of patient goals for health and social care into care plans and plan for future health needs.
• Undertake diagnostic assessments, health screening and therapeutic interventions and recommend further investigations, referring to other agencies as appropriate.
• Empower patients and their families through appropriate support and education.
• Maintain accurate patient records related to assessment and care planning.
• Support the development of clinical protocols and guidelines within own area of practice to ensure quality of care at all times.
• Review medication and act as a resource to other colleagues for medication advice and support in relation to care home patients.
• Discuss side effects and where appropriate prescribe within own NMP formulary and competencies relevant medication and liaise with pharmacy and medical staff.
• To regularly evaluate practice to ensure continuous improvement.
• Act as an advocate for the patient negotiating and consulting with other clinicians and associated staff to ensure high quality care.
• Work with the wider practice and PCN team in examining episodes of care delivery, critical incidents and individual care plans to improve and develop services.
• To support best practice end of life planning (last twelve months) including advance care planning for patients identified according to best practice end of life care.
• To work with patients and carers to develop care plans which encourage self-care and reduce avoidable hospital admissions.
• Contribute to the audit/board reports as required by the practices/PCN.
• Communication
• Utilise and demonstrate sensitive communication styles, to ensure patients are fully informed and consent to treatment.
• 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.
• Recognise the roles of other colleagues within their team, the organisation and their role to patient care.
• Use appropriate communication to gain the co-operation of relevant stakeholders (including patients, senior and peer colleagues, and other professionals, other NHS/private organisations e.g. ICBs).
• Work as a member of a team.
• Recognise personal limitations and refer to more appropriate colleague(s) when necessary.
• Actively work toward developing and maintaining effective working relationships both within and outside the practices/PCN and locality.
• Foster and maintain strong links with all services across the locality.
• Explore the potential for collaborative working and take opportunities to initiate and sustain such relationships.
• Liaise with stakeholders (as identified in Key Working Relationships) to ensure consistency of patient care and benefit.

Physical requirements

Essential

• Able to undertake the requirements of the post
• Full UK driving licence

Desirable

• Excellent attendance record

Qualities and Attributes

Essential

• A commitment to continuing personal and professional development.
• Ability to actively listen, empathise and provide personalised support in a non-judgemental way, inspiring trust, confidence and motivation.
• Ability to work as part of a team and build working relationships.
• Ability to deal with patients and their families sensitively.
• Proactive and forward thinking.
• Ability to respond to changing needs, pressure and demands and to organise and prioritise own workload.
• Reflective practitioner.

Qualifications

Essential

• Relevant professional qualification with affiliated professional registration RMN with NMC registration.
• Masters level degree in Advanced Clinical Practice.
• Evidence of Advanced Clinical Practice skills.
• Evidence of continuing professional development.

Desirable

• IRMER training

Experience & Knowledge

Essential

• Experience of working within multi-professional team environments.
• Post qualification clinical experience.
• Familiar with the interpretation of diagnostics and principles of shared clinical decision-making.

Desirable

• Leading multi-professional working within and across organisational boundaries.
• Experience of working in Primary Care.
• Have knowledge of chronic disease management reviews and QOF.
• Experience in a Frailty/Care Home setting.
• Experience of SystmOne and EMIS clinical systems.

Skills and competencies

Essential

• Ability to manage risk.
• Excellent communication skills, both written and verbal.

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).