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Advanced Nurse Practitioner

2 months 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 Primary Care Network. 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 services meeting their needs.
  • 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.

Responsibilities
  • Develop and implement person-centred shared care plans for patients, in collaboration with patients and through shared care planning with different healthcare professionals.
  • Support continual process improvement for the programme, making iterations in partnership with the Integrated Neighbourhood Team and PCN team as appropriate.
  • 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 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 healthcare provision and effectiveness of care.
  • Use technology and appropriate software, such as EMIS and the Manchester Shared Care Record, as an aid to management in planning, implementation, and monitoring of care, presenting and communicating information.