Pro-Active Care Nurse

The Proactive Care Nurse will proactively manage a defined caseload comprising patients identified within the frailest 10% of the population. Through comprehensive assessment, coordinated care planning, and timely intervention, the role focuses on identifying emerging needs early and addressing issues before they escalate. A key objective of the role is to reduce reliance on urgent and unplanned services, including emergency department attendances, non-elective hospital admissions, and urgent same-day interventions within primary and community care. This will be achieved through proactive case management, effective multidisciplinary collaboration, and continuity of care across health and social care services. The postholder will coordinate and deliver targeted interventions, ensuring patients receive responsive, joined-up support that promotes stability, wellbeing, independence, and high-quality care within the community. Key Tasks and Responsibilities Clinical Care and Assessment Conduct home visits to undertake comprehensive frailty assessments using the Comprehensive Geriatric Assessment (CGA) framework. Carry out holistic patient reviews to identify, monitor, and manage complex healthcare needs, including: social isolation falls risk mobility limitations nutritional concerns mental health needs Support the prevention of avoidable deterioration, crisis, and hospital admission through proactive intervention and monitoring. Provide clinical monitoring and long-term condition management for patients on the caseload, including: annual blood tests Quality and Outcomes Framework (QOF) reviews long-term condition reviews vaccinations where appropriate urine sampling mobile ECG monitoring Follow relevant clinical policies, protocols, and evidence-based guidelines. Personalised Care Planning Develop personalised care plans in partnership with patients and carers, ensuring plans: reflect outcomes and goals important to the individual promote independence and wellbeing include crisis and contingency planning are reviewed annually or sooner where clinically appropriate Ensure care plans are shared appropriately with relevant services, with patient consent. Ensure each patient on the caseload has a named clinician responsible for care coordination and oversight. Facilitate Advance Care Planning (ACP) and End-of-Life discussions where appropriate, ensuring patients wishes and preferences are documented and respected. Multidisciplinary Working and Care Coordination Work collaboratively as part of the Primary Care Network (PCN) multidisciplinary team alongside GPs, Proactive Care Nurses, Care Coordinators, Social Prescribers, community teams, and voluntary sector partners. Maintain regular communication with GP practices to support care planning, clinical oversight, and continuity of care. Collaborate closely with community healthcare providers including district nursing, physiotherapy, occupational therapy, intermediate care, falls services, and Older Peoples Mental Health teams. Participate in regular multidisciplinary team (MDT) and whiteboard meetings to review complex patients and coordinate care delivery. Delegate patient reviews and ongoing support appropriately within the multidisciplinary team and contribute to service and pathway development. Liaise with hospital teams during admissions and following discharge to support continuity of care and enhanced post-discharge support. Holistic and Preventative Support Take a holistic approach to wellbeing by supporting social prescribing and addressing wider determinants of health. Link patients and carers with appropriate NHS, social care, community, and voluntary sector services. Support patients to access Adult Social Care assessments, community resources, and ongoing support services. Promote equitable access to healthcare services, particularly for vulnerable or harder-to-reach patient groups. Documentation and Governance Record all patient consultations, assessments, and interventions accurately using EMIS templates and ensure records remain up to date. Following assessments, liaise with named GPs to ensure annual medication reviews are completed. Share relevant information appropriately and in line with information governance and patient consent requirements. Education and Service Development Support the learning and development of colleagues and students through supervision, joint visits, and shared learning opportunities. Contribute to the ongoing development of proactive care pathways and integrated neighbourhood working within the PCN. This job description outlines the main duties and responsibilities of the role and is not intended to be exhaustive. The postholder may be required to undertake additional duties appropriate to the role following discussion with their line manager.