Cluster Frailty & Chronic Conditions Practitioner

Use advanced nursing skill and expert knowledge to assess the physical and psychosocial needs of a defined client group, instigating treatment based on best available evidence in order to stabilise the individuals condition. To agree a personal management plan with the patient, ideally with inclusion of carers, relatives and other appropriate health care professionals. This will be based on a full assessment of medical, nursing and basic social care needs. To use advanced nursing skills and expert knowledge to identify subtle changes in the patients condition, analysing and interpreting complex health problems and associated scenarios. To work with patients to identify problems from their perspective and develop holistic management plans. To negotiate and agree with clients, carers, community nurse teams and other care professionals, individual roles and responsibilities with actions to be taken and outcomes to be achieved, referring on to other services or professionals as appropriate. To work across professional and organisational boundaries, identifying areas for skill and knowledge development applying these to individual practice with the aim of providing continuity and high-quality patient centred care. To enable patients and carers to manage their medications in conjunction with GPs, Pharmacists and other relevant clinical staff, including medication reviews as part of initial assessments and ongoing patient reviews. To provide expert clinical care and health promotion. Use expert knowledge and skill as a non-medical prescriber to independently prescribe within the individual practitioners areas of prescribing competency. Develop prescribing clinical management plans as appropriate in partnership with GP colleagues. Advanced care planning to improve communication and facilitate the co-ordination of patient care for those over 18 years of age at any stage of their health by involving the most appropriate professionals from health and social care, together with third sector providers. This will promote conversations between people, their families, carers and those looking after them, about their priorities, needs and preferences about their care now and in the future, enabling the relevant support to be provided enabling the appropriate delivery of care to meet these needs. Work to the NMC code of practice and maintain professional

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