Nurse Practitioner (Frailty Nurse) - Truro
Provide a first point of contact within the Practice for patients presenting, both in the Practice and over the phone, for patients presenting with undifferentiated, undiagnosed problems, making use of skills in history taking, physical examination, problem solving and clinical decision making, to establish a diagnosis and care management plan.
Instigate necessary invasive and non-invasive diagnostic tests or investigations and interpret findings and reports. Prescribe safe, effective and appropriate medication as defined by current legislative framework. Provide safe, evidence based, cost-effective, individualised patient care.
Refer patients directly to other services and agencies as appropriate. Provision of a holistic service to patients and their families, developing, where appropriate, an on-going plan or care and support, with an emphasis on prevention and self-care.
Contribute to the development and delivery of specialist primary care services, such as long-term disease management. Work with the Practice team to ensure that National Service Frameworks are being delivered. Contribute to the Practices achievement of its quality targets to maintain the high standards of patient care and service delivery.
Contribute to the development and set up of new patient services and participate in initiatives to improve existing patient services. Be aware of and contribute to planning and delivery of practice-based commissioning. FRAILTY NURSE- ROLE AND RESPONSIBILITIES Triage and allocate work appropriately via pro-active phone calls / visits to each care home once a week.
(Weekly ward-round). Focusing on health conditions: diagnose, manage, prescribe within bounds of own clinical knowledge. Arrange review by other clinicians where needed. Communicate details of all new/ changed medications to homes via email. Deal with ad-hoc requests from care homes through the week via home - initiated requests/ triage calls.
Plan any follow up/ review required. Ensure brief reason for any follow up appointments is added to the appointment screen. Work closely with GPs, PCN Care Coordinator, Consultant for Health Care of the Elderly Attend regular 1 hour MDT meeting for each home in rotation Manage chronic disease within own skill set and liaise with specialist teams as appropriate over time developing expertise in diabetes (including foot checks) Parkinsons disease, frailty, heart failure, dementia (and associated behavioural issues), delirium, asthma, COPD, falls, osteoporosis, B12 deficiency, vitamin D deficiency, deprescribing, nutrition in the frail elderly, anticoagulation and management of warfarin/ INRs Work to fulfil all QOF requirements and IIF requirements for care home patients, including seasonal vaccinations support.
Working with other members of the MDT (in particular Care Coordinator, Physician Associate and Pharmacist), ensure the requirements of the PCN care homes DES are fulfilled including review of new or re-admitted patients within 7 days, personalised care and support plans and structured medication reviews.Identify skin care/ leg care issues and required management pathway. Work effectively with community teams whilst avoiding taking on the workload of community nurses. Build links with social services, the Dementia and Older Peoples Mental Health Team, community physiotherapy and occupational therapy teams.
Aim to diagnose and code dementia where this is straightforward. Refer to DOPMH team when support with diagnosis or management is required. Refer patients where necessary e.g. hearing, eyes, dentist, specialist palliative care nurse, secondary care Participate in personalised care planning, treatment escalation plan and resuscitation status discussions and form completion Take a lead role in end-of-life care, including organisation of just in case drugs (in liaison with a GP) when needed Liaise with patients family where needed Identify when expected death forms may be required and highlight this to the relevant GPs/ liaise with visit liaison in reception to schedule visits appropriately Process pathology results/ reports/ letters/ requests for information for care home patients Complete community prescriptions when required (e.g. for B12 injections) Confirm death when needed Raise any concerns regarding quality of care or safeguarding with home managers and appropriate authorities.
Aim to manage demand from the care homes and avoid creating dependency this is only one small part of our work and has to be balanced against the needs of the wider group of patients registered with the practice. The duties of this post are wide-ranging and will require the post holder to be flexible in adapting to changing circumstances.Liaison As well as the nursing team there is a need to work closely with the General Practitioners, Management, Reception, Data, Pharmacy/Dispensary and Administration teams to ensure the smooth running of the Practice, reporting any problems encountered to the relevant person.
There is also the need to establish and maintain good liaison with other surgeries and agencies including secondary care. Administrative / Professional Responsibilities: Contribute to the identification and management of nursing care risks on a continuing basis.
Participate in practice meetings. Participate in audits as appropriate. Contribute to the setting up and improving practice systems for monitoring and measuring performance against Clinical Governance and Quality Indicator targets. Ensure practice policies are fully implemented.
To advise on policy within the continually changing environment of Primary Health Care delivery. To contribute and participate in the delivery of multidisciplinary education and clinical supervision. Participate in continuing professional development opportunities to ensure that up to date evidence based knowledge and competence in all aspects of the role is maintained.
Develop and maintain a Personal Development Plan. Maintenance of professional registration. To work within the NMC Code of Professional Conduct and Scope of Professional Practice, and to provide a high standard of professional conduct and nursing care at all times in accordance with the NMC.
Record accurate consultation data in patients records in accordance with the latest NMC guidance and other pertinent standards, ensure the clinical computer system is kept up to date with accurate details recorded and amended. Keep up to date with relevant health related policy and work with the practice team to consider the impact and strategies for implementation.
Work collaboratively with colleagues within and external to the Practice. Pro-actively promote the role of the Nurse Practitioner within the Practice and externally to stakeholders and agencies.