Specialist Proactive Care Nurse (Cross Gates PCN )
| Posting date: | 22 July 2025 |
|---|---|
| Salary: | £38,682.00 to £50,273.00 per year |
| Additional salary information: | £38682.00 - £50273.00 a year |
| Hours: | Full time |
| Closing date: | 04 August 2025 |
| Location: | Leeds, LS15 9JH |
| Company: | NHS Jobs |
| Job type: | Permanent |
| Job reference: | U0053-25-0035 |
Summary
Anticipatory and Person-Centred Care Planning: Working closely with the Frailty Team, you will lead and support the delivery of anticipatory care planning for individuals at risk of hospital admission, particularly those living with frailty, complex needs, or long-term conditions. Develop and monitor personalised care plans that reflect patient goals, preferences, and clinical needs. Early Identification and Clinical Reviews: Support the early identification of patients with deteriorating health through regular case-finding and clinical reviews, using tools such as the Frailty Index, Q-Risk, and professional judgement to inform proactive interventions. Comprehensive Holistic Assessment: Undertake thorough clinical assessments that consider physical, psychological, and social dimensions of care, supporting the delivery of safe, individualised, and effective treatment. Supporting Self-Management and Independence: Coordinate and deliver interventions that promote self-management, resilience, and independence, enabling patients to take an active role in their health and care planning. Community-Based Care Delivery: Conduct regular clinical reviews in clinic settings and provide home visits for housebound patients or those residing in care homes, ensuring continuity and equity of access. Health Promotion and Prevention: Deliver education, support, and interventions related to disease prevention, lifestyle modification, and health promotion. Engage with patients and communities to raise awareness of key public health messages. Screening and Vaccination Participation: Participate in seasonal vaccination programmes, NHS screening initiatives, and health surveillance campaigns, ensuring timely uptake and follow-up where needed. Chronic Disease Monitoring and Support: Provide clinical care and monitoring for patients with chronic conditions including diabetes, hypertension, chronic kidney disease, respiratory illnesses, and cardiovascular disease. Tailor interventions to meet individual clinical and lifestyle needs. Collaborative Clinical Management: Work closely with GPs, practice teams, and specialist services to optimise long-term condition management, reduce complications, and minimise hospital admissions. Evidence-Based Practice: Utilise clinical protocols, national guidelines, and best practice frameworks to deliver safe, effective, and personalised long-term care.