Adur Health Partnership

Chronic Disease Nurse

This job is now closed

Job summary

To be responsible for the implementation of processes for the effective management of patients with long-term conditions using evidence-based practice including care for elderly and housebound patients.

Working as a senior member of the practice multidisciplinary team, the post holder will ensure nursing services are delivered effectively to the entitled patient population.

The Chronic Disease Practice Nurse will be responsible for a number of clinical areas as well as actively supporting the management team in the reviewing and delivery of clinical policy and procedure.

Main duties of the job

Candidates will ideally have proven experience in a primary care setting and chronic disease management. We are looking for nurses with respiratory experience, ideally holding the ARTP spirometry qualification, and nurses who have experience of managing diabetes. Experience of other chronic conditions is desirable but not essential. Candidates will be qualified with an up to date NMC registration, plus evidence of continual professional development.

About us

This is a fantastic opportunity for an experienced Chronic Disease Nurse to join our well established nursing team.

Adur Health Partnership is a large, innovative GP Partnership based over 4 sites in Shoreham and Southwick, currently serving over 36,000 patients in our catchment area. We are also our own Primary Care Network as Shoreham & Southwick PCN. The Partnership is highly supportive with a strong sense of team, continually striving for improving the healthcare and well-being of our registered patients. Our organisation size and matching PCN footprint means we are primed to meet the demands of the ever changing GP contract and structure of the national PCN direct enhanced service, supporting our practice teams and also creating opportunities to support the community with wider possibilities.

Date posted

06 September 2023

Pay scheme

Other

Salary

Depending on experience

Contract

Permanent

Working pattern

Full-time

Reference number

A3277-23-0010

Job locations

Shoreham Health Centre

Pond Road

Shoreham-by-sea

West Sussex

BN43 5US

Job description

Job responsibilities

The following are the core responsibilities of the Chronic Disease Practice Nurse. There may be, on occasion, a requirement to carry out other tasks. This will be dependent upon factors such as workload and staffing levels:

a) To support the Infection Prevention Control (IPC) lead and support the implementation of audits, training, support and evidence of compliance to the Executive responsible

b) To support the production of the IPC annual statement in conjunction with the Lead Nurse

c) To develop, implement and embed an effective care management programme for the frail and housebound patients registered at the practice

d) To assess the needs of patients ensuring the provision of healthcare is appropriate, incorporating evidence-based practice

e) To develop, implement and embed health promotion and wellbeing programmes

f) To implement and evaluate individual treatment plans for chronic disease patients that promote health and wellbeing

g) To identify, manage and support patients at risk of developing long-term conditions, preventing adverse effects to patients health

h) As required, to provide routine nursing care to patients in accordance with clinical based evidence, NICE and the NSF

i) As required, to diagnose and manage acute and chronic conditions

j) To prescribe medication for patients in accordance with PGDs and own scope of practice

k) To review patient medications to enhance compliance

l) To provide guidance to patients in the use of prescribed and over-the-counter medications regarding side effects and dosages

m) To co-ordinate the provision of travel medicine services

n) To request pathology services and process pathology results as required

o) To maintain accurate clinical records in conjunction with extant legislation

p) To ensure snomed codes are used effectively by all members of the nursing team

q) To develop, implement, embed and participate in well woman clinics

r) To develop, implement, embed and participate in well man clinics

s) To ensure compliance with the practice chaperone policy

t) To assist GPs with minor surgery when required

u) To prioritise health issues and intervene appropriately

v) To support the team in dealing with clinical emergencies

w) To recognise, assess and refer patients presenting with mental health needs

x) To implement vaccination programmes for adults and children

y) To support patients in the use of their prescribed medicines or over-the-counter medicines (within own scope of practice)

z) To liaise with external services/agencies to ensure the patient is supported appropriately (vulnerable patients etc.)

aa) To delegate clinical responsibilities appropriately (ensuring safe practice and the task is within the scope of practice of the individual)

bb) To support the clinical team with all safeguarding matters, in accordance with local and national policies

cc) To understand practice and local policies for substance abuse and addictive behaviour, referring patients appropriately

dd) To deliver opportunistic health promotion where appropriate

In addition to the primary responsibilities, the Practice Nurse may be requested to:

a) Develop and review audit protocols and process for the practice, effectively utilising the audit cycle

b) Develop, review and implement nursing protocols in conjunction with the partners

c) Support all members of the nursing team, providing guidance when necessary, conducting appraisals and training needs analyses as required

d) Participate in local initiatives to enhance service delivery and patient care

e) Support and participate in shared learning within the practice in order to improve patient care

f) Continually review clinical practices, responding to national policies and initiatives where appropriate

g) Participate in the review of significant and near-miss events applying a structured approach, i.e., root cause analysis (RCA)

h) Coordinate the nursing team rota, ensuring sufficient staff are available to meet patient needs

i) Lead the planning and implementation of changes within the nursing team, enhancing the provision of services to patients

j) Support the practice team with the reviewing and implementation of practice policies and protocols, ensuring conformance to extant legislation