Advanced Clinical Practitioner for Proactive Care & Clinical Lead

Cross Gates Primary Care Network is seeking an experienced, forward thinking Advanced Clinical Practitioner to lead our Proactive Care Team and help shape the next phase of neighbourhood health in East Leeds. This is a senior Band 8a level role combining expert advanced clinical practice with clinical leadership, operational management, service development and system partnership working. The postholder will work alongside the PCN Clinical Director, GP Lead and PCN Manager to develop a coordinated, preventative and population based model of care.

The role will be central to redesigning how the PCN works with community, mental health, social care, local organisations and the voluntary sector. Cross Gates PCNs proactive care team supports people at greatest risk of deterioration, avoidable hospital admission with a strong focus on frailty, multimorbidity and complex health and social care needs., The Proactive Care Advanced Clinical Practitioner & Clinical Lead will provide clinical leadership and operational management of the PCN Proactive Care Team while undertaking advanced clinical practice.

The role leads delivery of proactive care, Enhanced Health in Care Homes, frailty pathways, personalised care planning and multidisciplinary working. The PCN provides enhanced proactive care to residents across four care homes, delivering ward rounds, multidisciplinary reviews, acute assessment, anticipatory care planning and proactive case management. The wider programme will expand proactive care across the PCN population using a population health management approach to identify and prioritise patients.

The postholder will independently assess, diagnose, treat and prescribe for patients with complex needs in care homes, patients' homes and community settings. As Clinical Lead, they will manage and develop the proactive care nursing team, provide clinical supervision, drive service improvement, and ensure delivery of agreed outcomes and integrated neighbourhood working, The PCN Proactive Care Team includes the GP Lead for Proactive Care, Specialist Proactive Care Nurse, Mental Health / Dementia Specialist Nurse, PCN Nurse, Nurse Associate, Clinical Care Coordinators and Clinical Pharmacists.

The team works closely with practice GPs, ACPs, Nursing Teams and Pharmacists alongside a Geriatrician, Community Matron, Neighbourhood Teams, Respiratory and Cardiology Specialist, Linking Leeds, Adult Social Care, Housing, the Local Care Partnership and third-sector organisations, Provide expert advanced clinical practice for people living with frailty, multimorbidity, complex needs and high risk of deterioration or avoidable hospital admission.

Lead the clinical and operational delivery of the PCN Proactive Care Team and ensure safe, effective and coordinated working across PCN practices and community settings. Lead implementation and delivery of the Proactive Care Programmes, including cohort identification, holistic assessment, personalised care planning, named care coordination and outcome monitoring. Lead care home Enhanced Health in Care Homes activity, ward rounds and MDT working in collaboration with practice GPs, ACPs, care home teams, pharmacists and community services.

Develop Cross Gates PCNs neighbourhood health model by strengthening integration, coordination and communication between primary care, community services, mental health, social care, public health, housing and the voluntary sector. Use population health management and clinical judgement to target those with greatest unmet need and address health inequalities and wider determinants of health. Promote prevention, early intervention and proactive care to reduce deterioration, crisis, unnecessary use of reactive services and avoidable hospital admission.

Outline of the Post 1. Advanced Clinical Practice Advanced assessment and treatment: Independently assess, examine, investigate, diagnose and treat patients with complex, undifferentiated, acute and deteriorating presentation