PCN Advance Nurse Practitioner

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 e.g., 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 e.g. 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