11 Oct
Hope Citadel Healthcare
Oldham
Job description
Job summary
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
Provideclinical leadership and supervision to the PHM care coordinator and other staffinvolved in the delivery of the Oldham South frailty model, particularly forthe management of care pathways of patients with complex cases.
Conductcomprehensive geriatric assessments to holistically assess the different needsof patients with mild or moderate frailty and identify those with complex needsand produce accurate and complete records of the patient consultation,consistent with legislation, policies and procedures.
Referpatients to health, care and other wider community-based services as needed forcontinuation of care where appropriate.
Conductassessment of patient activation in their own health to support referrals tohealth coaching where relevant
About us
This opportunity is for two or three ANPs to cover , it could be taken up by three people covering 3 posts or 2 people covering all three roles.
Oldham South Primary Care Network (PCN) is a network of 5 GP Practices lying within the Oldham Integrated Care System. Oldham South PCN services a population of around 43,000 patients.
Oldham North PCN is a network of 4 GP Practices lying within the Oldham Integrated Care System. Oldham North PCN services a population of around 42,000 patients.
Milltown Alliance PCN is a network of 8 practices lying across Chadderton and Werneth, who are working collaboratively with the aim of improving patient services, community wellbeing and through joint working will create efficiencies that can be re invested into the local community.
As PCNs, we are looking to grow our team of professionals focusing on a new population health management programme, to support more proactive and holistic care for people with mild to moderate frailty in our locality.
Job description
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 a) identifying where there may be health inequalities and providing feedback on where engagement could be enhanced;
- b) overseeing the quality and effectiveness of the PHM programme and working with the PCN team to use data and feedback to improve processes;
c) 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 , EMIS and the Manchester Shared Care Record as an aid to management in planning, implementation and monitoring of care, presenting and communicating information.
RESPONSIBILITIES TO PCN TEAMS
Actively develop effective working relationships and lines of communication within the practice, with the PCN, and with wider multi-professional teams across South Integrated Neighbourhood team District Nursing, Occupational Therapists,
Mental Health and Adult Social care services, as well as Social Prescribers and Pharmacists.
Demonstrates ability to work effectively as a member of a team with the practice and PCN Care Coordinator as a key person within the PHM model.
Can recognise personal limitations and refer to more appropriate colleague(s) when necessary.
Follow through with service users and others involved to ensure all services and care arrangements are in place.
Develops an in-depth knowledge of local health and care infrastructure and knows how and when to enable people to access support and services that are right for them.
RESPONSIBILITIES TO PATIENTS
Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing.
Ensure care plans are co-designed with patients around their needs and preferences
Communicate highly sensitive condition related information to patients, relatives and carers.
Undertake reviews of Patient Reported Outcome Meausures (PROMs).
Collaborate with other healthcare professionals to provide comprehensive care to patients.
Utilise and demonstrate sensitive communication styles, to ensure patients are fully informed and consent to treatment
Person Specification
Experience
Essential
- Advanced clinical practice skills
- Significant post registration experience
- 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
Desirable
- Knowledge of public health issues
- Project management
Skills
Essential
- Clinical leadership skills
- Change management
- Flexible approach and highly motivated.
- Evidence of excellent knowledge of using NHS IT systems such as EMIS.
Desirable
Communication skills training
Qualifications
Essential
- Experience within Primary Care.
- Registered first level nurse MSc or equivalent
- Relevant nursing / health degree
- Experience as an Advanced Nurse Practitioner
- Clinical supervision training and experience
▶️ PCN Advance Nurse Practitioner
🖊️ Hope Citadel Healthcare
📍 Oldham