Housebound Nurse

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Core Responsibilities: 1. Patient Assessment and Care Planning To assess, devise, and evaluate care plans for housebound patients, ensuring that their unique health needs are met in alignment with PCN and QOF care goals. Engage with patients, families, and caregivers to promote a patient-centred approach and ensure care aligns with both patient preferences and QOF targets. Identify patients suitable for pro-active care via the Frailty and integrated care team MDTs and remote monitoring programme. Referring as appropriate. 2. Clinical Responsibilities Conduct long-term condition reviews, including diabetes, cancer, learning disabilities, dementia, mental health, and blood pressure management, to support QOF performance and outcomes. Working in collaboration with practices/clinicians. Deliver specialist care in line with your scope of practice. Use prescriptive authority (where qualified) to enhance medication management, especially in managing long-term conditions, with attention to QOF outcomes. Provide patient and family education on managing health conditions, preventive care strategies, and self-management aligned with QOF indicators. 3. Leadership and Development Act as a clinical role model, delivering evidence-based care and contributing to the professional development of team members. Mentor supporting roles to achieve relevant patient outcomes. Oversee planning and co-ordination to support effective service delivery. 4. Clinical Governance, Audit, and Research Participate in clinical audits and research projects, implementing improvements based on findings to enhance patient care protocols. Contribute to the development and revision of PCN guidelines, protocols, and procedures, ensuring adherence to national and local standards, including QOF requirements. Actively engage in PCN quality improvement initiatives aimed at enhancing patient identification, assessment, and long-term support aligned with QOF. 5. Strategic and Collaborative Work Work proactively with PMs and directors to develop integrated care pathways, contributing to a holistic model of care. Advise on policy development and contribute to the PCNs strategic work streams.