Job summary
We are seeking a highly motivated ACP to join our Home Visiting Service (Team up) in Belper PCN. Team up aims to provide a holistic approach to our enhanced care service for housebound, frail, and elderly patients at home or in care homes, as well as those with complex health issues. Working within a multi-skilled and proactive team, and partnering with other service providers, Belper PCN home visiting Service strives to deliver a safe and effective service, while developing new ways of working and clinical pathways in line with key local and national clinical standards.
The successful candidate will provide advanced clinical expertise, sound judgement, discretion, and decision-making in the provision of clinical care to housebound people across the PCN. They will exercise a high degree of autonomy through the application of advanced clinical skills about the assessment, diagnosis, treatment and management of patients
The successful candidate will lead and monitor improvements to quality of care through clinical audit, evidence-based practice, clinical supervision, teaching, supporting professional colleagues and the provision of skilled professional leadership. They will lead the implementation of relevant clinical guidelines into practice and contribute to the further development of the evidence base through research and audit.
The successful candidate will lead the development of non-medical-led models of care within the primary and community care setting in collaboration with multi-professional colleagues and will play a crucial role in improving proactive management of patient care through timely assessment, referral, responsive intervention and anticipatory care planning.
Ideally, we are considering an 8 hour session per week with some flexibility to accommodate other commitments. If you are enthusiastic, team-oriented, and maintain a professional attitude, we would love to hear from you
Main duties of the job
Provides expert care to housebound patients with various medical conditions through comprehensive clinical assessments and an extended scope of practice. This includes conducting referrals, interpreting investigations, and independent prescribing.
Utilises a systematic approach to develop differential diagnoses and treatment plans while engaging patients, families, and caregivers in health priorities. Communicates sensitive information with empathy and refers patients to other practitioners as necessary. Evaluates therapeutic interventions and adapts management plans accordingly.
Assumes a leadership role in complex cases and maintains a strong clinical presence to enhance patient care outcomes. Offers guidance on therapeutic interventions, advance care planning, and decision-making for patients lacking capacity. Recognises patient deterioration and implements timely interventions.
Provides advice and education to relatives, caregivers, and professionals, applying expertise in palliative care. Demonstrates analytical thinking and professionalism to ensure a high-quality patient experience, integrating contemporary research and evidence-based practices in clinical pathways. Maintains accurate patient records in compliance with relevant standards.
About us
Belper PCN consists of 4 local GP practices working both together and with the broader health, social care, housing and voluntary organisations to improve the health and wellbeing of our local people. The vision for Team Up is to create one team across Health and Social Care that sees all housebound patients in a neighbourhood. Our team cover urgent, planned, and anticipatory care for our patients, working with a complete integration of local services. The team deliver care to those patients who are elderly, frail, and housebound.
Job descriptionJob responsibilities
JOB DESCRIPTION
The ACP areas of responsibility include: providing same-day urgent response to housebound patients; collaborating with the clinical team to ensure care home residents receive coordinated medical care, including proactive care planning and consistent support from a multidisciplinary team; participating in multi-disciplinary team meetings; recognising opportunities for anticipatory care of suitable patients through treatment plans; working with registered practices to ensure seamless care; leading and coordinating across organisations; delivering high-quality, methodical, and well-informed patient diagnoses and care plans; developing expertise within the community to improve the lives and care of the elderly; promoting the use of supportive, non-statutory services to support self-care and social prescribing agendas; and maximising the quality of care in patients' care homes to reduce the need for hospital admissions.
This job description is an outline of the tasks, responsibilities and outcomes required of the role. The job holder will carry out any other duties as may reasonably be required by the Clinical Lead. The following areas of responsibility are an indication of the role but could be subject to change as the impact of primary care network commissioning evolves.
Key areas of responsibility
Patient Care Provides expert care and advice to housebound patients presenting with a diverse range of medical conditions. Undertakes first line comprehensive clinical assessment of patients, including those with complex presentations, employing an extended scope of practice beyond own profession including advanced clinical assessment skills, referral and interpretation of investigations and independent prescribing. Requests, reviews and interprets diagnostic investigations within the context of other available information utilising a systematic process of clinical reasoning to formulate a differential diagnosis. Develops and records a treatment plan consistent with the outcome of assessment and the most likely diagnosis. Involves patients, families and carers in the identification of patient-centred concerns and priorities about health and wellbeing and negotiates approaches available to prevent deterioration or promote comfort and wellbeing. Demonstrates empathy and compassion when communicating sensitive information and advice to patients, carers and relatives. Refers to other practitioners and agencies when necessary. Evaluates the effectiveness of therapeutic interventions and modifies the management plan accordingly. Maintains a visible clinical profile, having both advisory and clinical input into the medical management of patients presenting to the service. Advises health and social care teams with regard to medical management plans taking into account all aspects of clinical governance to improve the outcomes of patient care. Assumes a lead role in the safe and effective transfer of care for more complex cases.
Demonstrates a high degree of autonomy, analytical skills, competency and multidisciplinary knowledge in caring for the older person. Assesses capacity, gains valid informed consent and works within a legal framework with patients who lack capacity to consent to treatment. Provides guidance to the clinical team with regard to therapeutic interventions, advance care planning and best interest decision-making for patients who lack mental capacity to make informed choices about their care. Recognises deteriorating patients, implements early interventions and escalates care where appropriate. Empowers patients to manage their long-term conditions as independently as possible. Provides verbal and written advice, teaching and instruction to relatives, carers and other professionals, to promote understanding and to ensure a consistent approach to patient care. Applies expert knowledge in palliative care to symptom control, recognition of dying and advance care planning. Demonstrates analytical thinking, decision making, professionalism and leadership to ensure a high quality patient experience within a multi-professional arena. Facilitates the integration of contemporary research and best practice through advanced clinical reasoning and decision making and the implementation of evidence-based protocols of care and clinical pathways. Maintains accurate and legible patient notes in accordance with the memorandum of understanding and professional guidance.
Strategy and Service Development
Professional Leadership and Consultancy
Shares and contributes expertise locally and nationally.
Facilitates and promotes a learning culture that encourages others to develop their full potential.
Communicates, motivates and inspires others to deliver excellent standards of care.
Acts as an acknowledged source of expertise to assist with the development of service delivery models
and clinical guidelines and to promote their application throughout the organisation.
Challenges restrictive cultures and champions new ways of working to deliver enhanced patient
focused care and improved productivity amongst the workforce.
Works closely with medical, social care and therapy colleagues to deliver fully integrated team led care.
Contributes to the development of Advanced Clinical Practice across organisations.
Encourages other healthcare professionals to disseminate good practice.
Supports the development of a learning organisation by identifying, challenging and reporting poor
performance and alerting managers to resource issues which may affect patient safety.
Actively contributes to appropriate service developments and quality improvements.
Training, Education and Staff Development
Participates in the development of a research portfolio and clinical audit programme in relation to care
of the elderly.
Disseminates research findings within clinical teams and identifies strategies for implementation in
practice.
Assumes responsibility for own continuing professional development in relation to role and contributes
to the continuing professional development of other healthcare professionals.
Makes effective use of learning opportunities whilst contributing to developing the workplace as a
learning environment.
Undertakes annual mandatory training updates and other relevant courses in line with PCN policy.
Acts as a resource for the clinical team.
Practice and Service Development Makes recommendations for and leads change. Shapes services for older people in accordance with local and national policies and drivers. Monitors and challenges risk in relation to their own practice and that of colleagues. Acts as a champion and advocate for the care of the frail older person.
Financial Resources/Management
Manages available resources efficiently.
Prescribes and manages medications in accordance with local prescribing guidelines and prescribing
budget.
Advises budget holders on value for money purchasing of equipment required in this area of clinical
practice.
Information Resources/Information Systems
Analyses and interprets highly complex information gained during clinical examination and history
taking to diagnose an individuals problem or illness and to decide on an appropriate course of action or
treatment.
Identifies evidence based interventions to meet an individuals complex health needs within the context
of the overall management plan.
Undertakes critical analysis of contemporary research studies and incorporates valid research findings
into practice.
Identifies areas which require further research or audit and instigates collaborative research/audit
projects.
Evaluates the quality of own work and current practices through the use of evidence based practice
projects, audit and outcome measures and supports others in doing so.
Develops benchmarks for best practice, identifies quality outcome measures and contributes to audit
programmes.
Identifies and agrees the minimum data set to be collected by self and others within the team and
implements agreed methods of data collection.
Analyses the information obtained using appropriate methods and reports the findings in a timely
manner.
Supports the team in collating and analysing the information obtained in relation to their area of
responsibility and encourages timely reports of the data and information obtained.
Maintains contemporary knowledge of clinical guidelines relevant to practice and acts consistently with
associated quality standards.
Autonomy/Scope within Role
Assumes clinical accountability for the delivery of patient care.
Practices competently and autonomously without direct supervision in accordance with professional
code of practice and local policies and procedures.
Acknowledges limitations in own professional competence and only undertakes practice and accepts
responsibilities for those activities for which competence can be assured.
Exercises professional judgment and expertise to create precedents and deal with ambiguous or novel
problems.
Applies best practice policy guidelines where appropriate and in the absence of specific guidance
Person SpecificationQualificationsEssential
- Professional registration with NMC, HCPC or GPhC
- Evidence of post-registration study at Master's Level
- Experience of mentoring and coaching
- PGDip in Advanced Clinical Practice (or equivalent).
- Independent Prescriber
Desirable
Experience Essential
- Experience of working with older individuals who have complex needs
- - Involvement in a multi-professional team
- - Expertise in end-of-life care
- - Practical knowledge of primary care and community services
- - A minimum of 5 years of clinical experience, including at least 3 years in a senior role, with people with complex needs
Desirable
- Involvement in service improvement
- Implementation of best practice
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Pay: £57,528.00-£64,750.00 per year
Benefits:
- Company pension
- Free parking
- On-site parking
- Sick pay
Work Location: In person
