Registered Nurse - Long Term Conditions

Role Purpose The Collaborative Care team (CCT) is a multi-disciplinary team which provides proactive assessment and support to people living with Frailty and long-term conditions, promoting independence at home and preventing unplanned admissions to hospital. The team coordinate services across the local health and care economy within Northants for people who have complex care needs. The Long-Term Conditions (LTC) Registered Nurse will provide high-quality, patient-centred nursing care to adults living with one or more long-term health conditions within the community setting. The post holder will support patients to optimise self-management, improve health outcomes, reduce unnecessary hospital admissions, and enhance quality of life through proactive assessment, care planning, education, and clinical intervention. The role involves working collaboratively with multidisciplinary teams, primary care providers, social care, voluntary sector organisations, and family carers to deliver coordinated care that meets the physical, psychological, and social needs of patients.

Accountable to

Collaborative Care Team Clinical Lead Role Responsibilities Undertake comprehensive physical, psychological, and social assessments of patients with long-term conditions and develop person centred care plans through shared decision making. Conduct routine and specialist reviews for patients with long-term conditions including Chronic Obstructive Pulmonary Disease (COPD), Asthma, Diabetes, Heart Failure, Hypertension, Coronary Heart Disease, Chronic Kidney Disease, Frailty and multi-morbidity. Undertake clinical procedures including Venepuncture, Blood pressure monitoring, ECG recording, Wound assessment and care, Urinalysis, Point-of-care testing where appropriate. Diabetic foot screening Coordinate care across multiple services and providers and participate in multidisciplinary team meetings and case discussions. Promote healthy lifestyles and preventative healthcare measures by providing education and coaching to enable patients to self-manage their conditions effectively. This includes encouraging the uptake of screening, immunisation, and health checks. Identify barriers to self-management and develop strategies to overcome them. Undertake risk assessments relating to health, wellbeing, mobility, nutrition, and environmental factors and implement risk management plans to maintain patient safety. Provide clinical leadership for Nursing Practice and support and supervise junior staff including healthcare support workers and students. Contribute to service development and quality improvement initiatives and participate in clinical audit, research, and evaluation activities. Maintain professional competence through continuing professional development and participate in clinical supervision, appraisal, and professional revalidation.