Registered Nurse - Long Term Conditions

The Long-Term Conditions (LTC) Registered Nurse will provide high-quality, patient-centred nursing care to adults living with one or more long-term health conditions within the community setting. The post holder will support patients to optimise self-management, improve health outcomes, reduce unnecessary hospital admissions, and enhance quality of life through proactive assessment, care planning, education, and clinical intervention.

Role Purpose

The Collaborative Care team (CCT) is a multi-disciplinary team which provides proactive assessment and support to people living with Frailty and long-term conditions, promoting independence at home and preventing unplanned admissions to hospital. The team coordinate services across the local health and care economy within Northants for people who have complex care needs.

The Long-Term Conditions (LTC) Registered Nurse will provide high-quality, patient-centred nursing care to adults living with one or more long-term health conditions within the community setting. The post holder will support patients to optimise self-management, improve health outcomes, reduce unnecessary hospital admissions, and enhance quality of life through proactive assessment, care planning, education, and clinical intervention.

The role involves working collaboratively with multidisciplinary teams, primary care providers, social care, voluntary sector organisations, and family carers to deliver coordinated care that meets the physical, psychological, and social needs of patients.

Accountable to: Collaborative Care Team Clinical Lead

Role Responsibilities

• Undertake comprehensive physical, psychological, and social assessments of patients with long-term conditions and develop person centred care plans through shared decision making.
• Conduct routine and specialist reviews for patients with long-term conditions including Chronic Obstructive Pulmonary Disease (COPD), Asthma, Diabetes, Heart Failure, Hypertension, Coronary Heart Disease, Chronic Kidney Disease, Frailty and multi-morbidity.
• Undertake clinical procedures including Venepuncture, Blood pressure monitoring, ECG recording, Wound assessment and care, Urinalysis, Point-of-care testing where appropriate. Diabetic foot screening
• Coordinate care across multiple services and providers and participate in multidisciplinary team meetings and case discussions.
• Promote healthy lifestyles and preventative healthcare measures by providing education and coaching to enable patients to self-manage their conditions effectively. This includes encouraging the uptake of screening, immunisation, and health checks.
• Identify barriers to self-management and develop strategies to overcome them.
• Undertake risk assessments relating to health, wellbeing, mobility, nutrition, and environmental factors and implement risk management plans to maintain patient safety.
• Provide clinical leadership for Nursing Practice and support and supervise junior staff including healthcare support workers and students.
• Contribute to service development and quality improvement initiatives and participate in clinical audit, research, and evaluation activities.
• Maintain professional competence through continuing professional development and participate in clinical supervision, appraisal, and professional revalidation.

PML is a successful not-for-profit, GP-led organisation providing various NHS community and primary care clinical services to patients across Oxfordshire and Northamptonshire. We have evolved as a NHS healthcare provider since 2004 and in the last few years have grown significantly, now employing around 300 staff with a turnover of circa £16m. PML holds GMS contracts, as well as being a GP Federation representing circa 50 GP practices covering approximately 650,000 patients.

We welcome applicants from a diverse range of backgrounds and circumstances and people with protected characteristics under the Equality Act 2010

Essential: - Experience of community, primary care, or integrated care services.

Desirable: - Frailty and complex care management.

Essential: - Registered Nurse (Adult) with current NMC Registration; - Recognised qualification or considerable experience in management of long-term conditions.

Desirable: - Mentorship or Practice Assessor qualification

Essential: - Sound clinical knowledge of long-term condition management.; - Excellent assessment and clinical decision-making skills.; - Strong communication and interpersonal skills.; - Ability to work independently and manage workload effectively.; - Competence in clinical record keeping and IT systems.; - Understanding of safeguarding legislation and procedures.; - Full UK driving licence and access to a vehicle for work purposes (where required).; - Ability to travel across community locations.

Desirable: - Knowledge of national healthcare priorities and integrated care pathways