Job responsibilities

The following are the core responsibilities of the ANP in delivering health services.

a. Develop, implement and embed health promotion and wellbeing programmes

b. Manage patients presenting with a range of acute and chronic medical conditions, providing subject matter expert advice

c. Implement and evaluate individual specialised treatment plans for chronic disease patients

d. Identify, manage and support patients at risk of developing long-term conditions, preventing adverse effects to the patients health

e. Provide advanced, specialist nursing care to patients as required in accordance with clinical based evidence, NICE and the NSF

f. Be aware of duties and responsibilities regarding current legislation and adhere to practice policies and procedures on Safeguarding Adults and Safeguarding Children

g. Request and collect pathological specimens. Upon receipt, to process and interpret pathology and other test results as required

h. Provide chronic disease clinics, delivering patient care as necessary, referring patients to secondary/specialist care as required

i. Maintain accurate clinical records in conjunction with extant legislation ensuring that SNOMED CT codes are used effectively

j. Maintain chronic disease registers and implement and embed an effective call/recall system

k. Develop, implement and embed well woman and well man clinics

l. Chaperone patients where necessary

m. Prioritise health issues and intervene appropriately

n. Support the team in dealing with clinical emergencies

o. Recognise, assess and refer patients presenting with mental health needs

p. Support in the provision of vaccination programmes for both adults and children

q. Be an extended and supplementary prescriber, adhering to extant guidance

r. Support patients in the use of their prescribed medicines or over the counter medicines (within own scope of practice), reviewing annually as required

s. Contribute to practice targets (QOF, etc.), complying with local and regional guidance

t. Liaise with external services/agencies to ensure the patient is supported appropriately (vulnerable patients, etc.)

u. Delegate clinical responsibilities appropriately (ensuring safe practice and that the task is within the scope of practice of the individual)

v. Understand practice and local policies for substance abuse and addictive behaviour, referring patients appropriately

w. Deliver opportunistic health promotion where appropriate

x. Support Home Visits where possible

y. Support on-line triage and duty team

There may be, on occasion, a requirement to carry out other tasks, this will be dependent upon factors such as workload and staffing levels

Experience

Essential

• Understanding of general practice and the wider NHS
• Experience of practice within the four pillars
• Experience of leading in chronic disease management
• Experience of prescribing and undertaking medication reviews
• Experience of infection prevention and control measures
• Experience of quality initiatives, i.e., benchmarking

Desirable

• Experience of working as a practice nurse or community nurse
• An appreciation of the new NHS landscape including the relationship between individual organisations, PCNs and the commissioners

Clinical Knowledge and Skills

Essential

• Understanding of the importance of evidence-based practice
• Ability to promote best practice regarding nursing matters
• Clinical knowledge and skills including:
• ECGs
• Venepuncture
• Chaperone procedure
• Requesting and processing pathology tests
• Advising patients accordingly
• Diabetes
• Hypertension
• Asthma
• Spirometry
• CHD
• Womens health (cervical cytology, contraception, etc.)
• Ability to work within own scope of practice and understanding when to refer to GPs

Qualifications

Essential

• Registered Nurse with Nursing and Midwifery Council (NMC)
• Masters degree required for qualification post December 2020 refer to RCN Credentialing for Advanced Level of Nursing Practice (ALNP) or, a degree for Advanced Practice Qualification up to December 2020
• Qualified Independent Nurse Prescriber on the NMC register
• Has evidence of working at an enhanced level, as described in the Primary Care and General Practice Nursing Career and Core Capabilities Framework
• Meets NMC revalidation requirements in accordance with the NMC Revalidation booklet
• Confirmation of registration with the NMC
• Minor illness qualification

Desirable

• Qualified triage nurse
• Teaching qualification
• ALS and PALS

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.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Job responsibilities

MDT working:

• To have an awareness of key MDT targets and priorities in terms of the operational/strategic plan for the system and related initiatives; to actively support the organisation in delivering high quality care and maintaining Care Quality Commission Compliance (CQC).
• To comply with relevant national guidelines, including NICE Guidance and National Standards Framework and within a scope of your own clinical standards.
• To contribute to the identification and development of relevant clinical protocols and strategies to enhance both the continuity and standard of specialist care whilst ensuring equity of access to the service, ensuring that all care is given in accordance with agreed protocols.
• To work with the MDT to develop, implement and evaluate integrated care pathways and systems .
• Participate in policy development through professional forums and implement practice ensuring the clinical practice reflects national and local drivers

Communication:

• Maintain and foster good relationships with all colleagues concerned with the provision or development of healthcare services.
• Forge effective links within Primary, secondary and community services to ensure effective communication through appropriate forums.
• Timely recording patient activities for IT data collection, dealing with e-mail queries, stock and equipment ordering.
• Preserve confidentiality and compliance to GDPR, Data Protection Act, Access to Health Records and Consent for Treatment.
• Demonstrate good communication skills to facilitate effective communication with patients and their carers, including sensitive and accurate information about their condition.
• Provide and receive complex, sensitive and confidential information and overcome potential barriers to communication, such as language, disability.
• Inform other professionals about changes in patients' condition.
• Act as a patient advocate as required ensuring individual needs, preferences and choices are delivered by the Service.

Education & Training:

• Assume responsibility for own professional development and personal knowledge.
• Monitor own performance against agreed objectives through the process of IPR and personal development plans, Professional regulations and maintain professional expertise by arranging and attending meetings, study days and in service training for the team members.
• Facilitate and develop team members.
• Participate in Reflective Practice, Practice Supervision and Appraisals as per organisational) policies.
• Support student development and placement
• Plan and participate in the supervision, teaching and provision of community experience for all nurse learners and other personnel as appropriate.
• Develop the learning environment to promote lifelong learning and staff development. Identify areas of practice/role development and enable and support staff to initiate change.
• Work towards becoming an Independent Prescriber

Care home support responsibilities, as required:

(may include covering team absence or annual leave)

• If required support weekly check-in meetings with homes - which should include: facilitating and managing the delivery of the review (either remotely or in person, wherever appropriate), facilitated by an MDT where practically possible.
• Review patients identified by the care home as a clinical priority for assessment, review any new residents.
• Support the provision of care for those patients identified as a clinical priority; include appropriate and consistent medical oversight with liaison / input from a GP and/or geriatrician (with the frequency and form of that input determined by clinical judgement).
• Support homes with end of life care planning as required
• Support homes as appropriate with care planning establishing a process to:
• Support development of personalised and individually agreed treatment escalation plans for care home residents with care home teams, including end of life care plans.
• The role should work towards implementing the Comprehensive Geriatric Assessment.
• Facilitate the timely appropriate use of medication reviews, working with the Pharmacy Technician, including:
• medication supply , including end of life medication.
• Arranging the delivering structured medication reviews - via video or telephone consultation where appropriate - to care home or housebound residents.
• Supporting reviews of new residents or those recently discharged from hospital to patients home or care home beds
• To support older patients and patients with moderate and severe frailty in their own homes by:
• Identification of patients using an agreed case finding tool (Electronic Frailty Index [eFI] or Rookwood score) who require completion of a Comprehensive Geriatric Assessment (CGA). Patients should be considered for MDT/caseload management following assessment.
• Participating in annual reviews for housebound patients with long-term chronic conditions.
• Signposting to other services/voluntary sector as appropriate and to consider social prescribing, (for example, in support of alleviating loneliness brought on by social isolation)
• Attendance at Multi-Disciplinary Team (MDT) meetings

Experience

Essential

• - Understanding of the particular requirements of elderly patients within an acute and community setting and the knowledge and skills to assess patients with commonly recognised admission criteria E.g. Falls, Urinary Tract and Lower Respiratory tract infections, Delirium and Dementia, heart failure and COPD/asthma exacerbations.
• - Ability to prioritise individuals for assessment and management according to their health status and needs, referring for specialist assessment, diagnostic tests and programs of support as appropriate.
• Develop person led single geriatric care plans in partnership with patients and their relatives.
• - Initiate and ensure Advanced Care Planning is undertaken at appropriate stage of disease process/frailty trajectory, ensuring patients goals are met when requiring palliative care or end of life care in line with Local Organisational End of Life Strategy and NICE Clinical Guidelines.

Desirable

• - An autonomous practitioner who will provide expert clinical case management for Care Home and frail patients with acute/intensive medical needs and at risk of further deterioration in health that may result in avoidable hospital admission or unnecessary length of hospital stay.
• - Responsible for facilitating efficient, effective coordinated assessments and treatment for frail adults under supervision of Clinical Frailty lead
• Gathering and interpreting information from various IT systems and sources, performing tests and analysing results, recording collated information using a Single Assessment Pathway Support.
• - Facilitate person led early discharge plans working in collaboration with hospital MDT and discharge teams ensuring the patient's needs are met and likelihood of unnecessary readmission is reduced.
• - Actively seeking out patients who will benefit from clinical case management technique in order to avoid unplanned hospital admission and reduce the length of hospital stays.
• - Ability to prioritise individuals for assessment and management according to their health status and needs, referring for specialist assessment, diagnostic tests and programs of support as appropriate.
• - Commitment to provide clinical support to patients, their families/carers and professionals involved across the Frailty pathway.
• - Use a high level of communication and interpersonal skills to communicate effectively with patients and carers, in particular the skills needed for cognitive assessment and mental health status.
• - Integrating the three key aspects of clinical practice, education and research whilst collaborating closely with other members of the multi-disciplinary team to develop and monitor standards of care.
• - Establish and maintain excellent communication with individuals and groups, exploring complex issues relating to care options and decisions and sustain effective working relationships across all health and social care service organisations.
• - Support the delivery of frailty audit and service improvement initiatives.
• - Using referral criteria, clinical knowledge and experience identify and assess patients who are suitable for a full CGA assessment.
• - Completion of CGA including collateral social and past medical history from patients, family, care providers, community and primary care services.
• - Document full CGA and formulate an appropriate plan.
• - Refer to MDT to identify, review and support patients with complex disease management who are either at risk of admission, have repeated active hospital admissions to develop their knowledge and understanding about their health and well-being to enable self- management within individual abilities.
• - Enhanced Care Planning for end of life patients and completion of Treatment Escalation Plan (TEP).

Other requirements

Essential

• Driving licence and vehicle are required for this role.

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.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).