Population Health Management Advanced Nurse Practitioner

5 days ago

Oldham, Oldham, United Kingdom Hope Citadel Healthcare CIC Full time
Job Summary

The Population Health Management Advanced Nurse Practitioner will play a pivotal role in supporting the delivery of the Population Health Management Programme across the PCN. This programme focuses on providing proactive support and case management to individuals over 65 with mild to moderate frailty, enabling them to remain healthier in their own homes.

Main Responsibilities
  • Lead the assessment of patients over 65 with mild to moderate frailty, identifying those suitable for the programme and inputting into their care plans.
  • Support the leadership of the PHM care coordinator in identifying and engaging individuals to intervene early, maintain good health, prevent deterioration, and ensure access to necessary services.
  • Collaborate with the Integrated Neighbourhood Team and PCN team to create care plans, working within the PCN team and across an integrated neighbourhood team of different health and care professionals.
  • 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, producing accurate and complete records of the patient consultation.
  • 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.
About Us

Oldham South Primary Care Network (PCN) is a network of 5 GP Practices within the Oldham Integrated Care System, serving a population of around 43,000 patients. This opportunity is for two or three Advanced Nurse Practitioners to cover the role, which could be taken up by three people covering 3 posts or 2 people covering all three roles.

Person Specification
  • 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
Responsibilities
  • 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.

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