Proactive Care / Care Homes ANP

Job responsibilities

1. Clinical Practice

• Deliver advanced, holistic clinical care to patients in care home settings.
• Identify and respond to early signs of deterioration, including escalation planning.
• Assess and manage acute, chronic, and complex conditions related to frailty.
• Prescribe and deprescribe safely within scope of practice and professional competencies.
• Undertake Comprehensive Geriatric Assessments to inform care planning and coordination.
• Order, perform, and interpret diagnostic tests and investigations.
• Initiate diagnosis for long-term conditions (e.g. diabetes, COPD, asthma, IHD) and refer appropriately.
• Directly admit patients to secondary care when clinically indicated.

2. Care Planning and Coordination

• Deliver proactive, anticipatory, and advance care planning using evidence-based tools (e.g. ReSPECT, EPaCCS).
• Undertake holistic, person-centred needs assessments and develop individual care plans.
• Maintain and manage a caseload of care homes patients.
• Collaborate with the multidisciplinary team (MDT) to develop and implement patient-specific care pathways.
• Proactively manage long-term conditions and support admission avoidance strategies.

3. Communication and Collaborative Working

• Work independently and in partnership with GPs and the wider MDT.
• Communicate effectively with healthcare professionals to ensure coordinated care.
• Build and maintain strong relationships with statutory, voluntary, and third-sector organisations.
• Organise, chair, and contribute to MDT meetings to support integrated care delivery.
• Advocate for patients and families where necessary.

4. Health Promotion and Patient Support

• Promote health, wellbeing, and independence for patients in care home settings.
• Provide education to patients and carers to support self-management and behaviour change.
• Support vaccination programmes within care homes.
• Deliver education and guidance to care home staff (e.g. nutrition, hydration, oral care, ReSPECT planning).

5. Service Delivery and Development

• Work flexibly across GP practices, and care homes
• Support Proactive Care Coordinators in delivering high-quality care.
• Contribute to service development and innovation in Proactive Care pathways.
• Participate in audits, data collection, and quality improvement initiatives.
• Contribute to achieving local and national targets and maintaining disease registers.

6. Administration and Governance

• Maintain accurate, contemporaneous patient records using EMIS and SystmOne.
• Ensure compliance with CQC standards and relevant policies (e.g. infection control, safeguarding, risk management).
• Promote safe medication management practices.
• Support effective communication within the PCN and across partner organisations.
• Contribute to contractual and reporting requirements.

7. Professional Development

• Maintain high standards of professional practice, conduct, and clinical excellence.
• Participate in appraisal processes and align objectives with organisational goals.
• Undertake mandatory training and continuing professional development.
• Keep up to date with current guidelines, policies, and contractual changes.
• Engage in reflective practice and lifelong learning.

General Responsibilities

• Attend and actively contribute to team, practice, and PCN meetings.
• Work within all relevant policies, procedures, and professional standards.
• Maintain confidentiality and uphold information governance requirements.
• Carry out any other duties commensurate with the role.

Key Working Relationships

PCN Clinical Director

Proactive Care Team

PCN Clinical Leads

GPs, Practice Managers, nurses and other practice staff.

PCN teams - Clinical Pharmacists, Social Prescribers, Dietician, Health and Wellbeing Coaches.

Providers of care including acute trusts, independent sector and providers, neighbourhood teams, community services, geriatricians, community matrons, community mental health services.

Local Care Partnerships linked to the PCN

Confidentiality

Ensure that confidentiality is adhered to in terms of patient information and the protection of personal and sensitive data.

Health and Safety

Identify risks involved in work activities and undertake activities in a way that manages risks.

Actively report health and safety hazards and infection hazards immediately when recognised.

Maintenance of general standards of cleanliness consistent with the scope of the role.

Equality and Diversity

Act in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with PCN practice procedures and policies, and current legislation.

Be familiar with and adhere to PCN practice safeguarding policies, procedures and guidelines for both children and adults at risk of abuse or neglect in conjunction with Multi-agency Safeguarding Children and Safeguarding Adults at risk of abuse and/or neglect policy, protocols, and guidelines.

Person Specification

Knowledge & Skills

Essential

• - Understanding of Personalised Care
• - Understanding of the wider determinants of health
• - Knowledge of how the NHS works, including primary care and PCNs
• - Ability to recognise/work within limits of competence, seeking advice if needed
• - Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• - Basic knowledge of long-term conditions and associated complexities: medical, physical, emotional and social
• - Clear, polite telephone manner
• - Good interpersonal skills
• - Ability to record accurate clinical notes
• - EMIS and SystmOne user skills
• - Proficient in MS Office and web-based services

Personal Qualities

Essential

• Teamwork: Work effectively and professionally within the frailty team through willingness to proactively support and assist peers and colleagues
• Autonomous: Ability to work independently by making informed decisions based on professional knowledge and clinical judgement
• Solution Focussed: Ability to react to and face challenges or setbacks in a positive manner with a commitment to continuous improvement
• Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities
• ...