Job Description
Job summary
Cross Gates Primary Care Network is seeking an Advanced Clinical Practitioner to join our established Proactive Care Team. This is a senior autonomous clinical role focused on prevention, frailty, complex care, care homes and admission avoidance, working as part of an integrated neighbourhood model across East Leeds.The ACP will work closely with the Proactive Care Clinical Lead, GP Lead for Proactive Care, PCN clinicians, Clinical Care Coordinators and wider neighbourhood partners to deliver personalised, preventative and coordinated care
Main duties of the job
The postholder will provide advanced clinical assessment and management for people at greatest risk of deterioration, avoidable hospital admission or loss of independence, with a particular focus on frailty, multimorbidity, complex health and social care needs and care home residents. The role will include autonomous assessment, diagnosis, investigation, treatment, prescribing, care planning and referral in care homes, patients own homes and other community settings.
Job description
Provide autonomous advanced clinical assessment, examination, diagnosis, investigation, treatment and prescribing for people with complex, undifferentiated or deteriorating presentations.
Undertake care home ward rounds, acute and planned home visits, proactive frailty reviews and community-based clinical reviews.
Develop and review holistic personalised care plans, anticipatory care plans and treatment escalation plans with patients, carers and the wider MDT.
Use population health data, Proactive Care dashboards, PQI reports and clinical judgement to identify people at greatest risk and target proactive intervention.
Work collaboratively within care home and proactive care MDTs, contributing expert clinical assessment, decision-making, referral and follow-up.
Support prevention, admission avoidance, medicines optimisation, self-management, independence and timely access to community alternatives to hospital.
Actively participate in seasonal vaccination programmes for care home, housebound and proactive care cohorts, working with Clinical Care Coordinators and PCN clinicians to improve uptake and prevent avoidable illness.
Contribute to service evaluation, audit, quality improvement, coding, data quality and delivery of Proactive Care and Enhanced Health in Care Homes requirements.
Provide clinical advice, teaching and peer support to colleagues within scope of expertise, while participating in regular clinical supervision and continuing professional development.