HCA focused on Chronic Disease Management

Deliver structured annual review appointments for patients with Type 2 diabetes, hypertension, cardiovascular disease (CHD, stroke/TIA, PAD, AF), heart failure, CKD, COPD, asthma, and other long-term conditions. Complete the eight diabetes care processes (BMI, BP, HbA1c, foot risk stratification, urinary ACR, serum creatinine, smoking status, cholesterol). Undertake blood pressure measurement, including ambulatory and home BP monitoring set-up and download. Carry out urinalysis and arrange/process urine ACR samples. Carry out diabetic foot risk stratification and basic foot assessment (training supported). Record height, weight, BMI, waist circumference, pulse and oxygen saturations. Calculate and record QRisk and Q-Diabetes scores where indicated. Record smoking and alcohol status (including AUDIT-C) and provide brief lifestyle advice and onward signposting. Complete depression screening (PHQ-2/9), dementia screening prompts and frailty screening as part of Part A reviews. Identify carers, complete carer enquiry and refer to social prescribing as appropriate. Support delivery of NHS Health Checks, new patient checks and travel health screening as required. Administer B12 injections, flu and other vaccinations within Patient Group Directions / Patient Specific Directions and individual competency. Provide chaperoning as required. Support care home rounds and chronic disease work in care home residents in line with the Supplementary Care Home Service Specification. Use EMIS Web and Accurx accurately and efficiently, ensuring correct clinical and payment coding for QOF, PCQOF and LES reviews.