Frailty Nurse/ Paramedic Prescriber (Proactive Neighbourhood Care)NHS

Job summary

The Proactive Neighbourhood Care and Remote Monitoring service will support people living with frailty, complex needs and those who are housebound. The service will combine proactive home visiting, care coordination, remote monitoring and links into wider neighbourhood and Local Authority support.

The Frailty Prescriber will provide autonomous clinical assessment and treatment for people living with frailty and complex needs, mainly in their own homes. The role will combine proactive clinical review, medicines optimisation, care planning, remote monitoring escalation and close working with general practice and wider neighbourhood teams.

Main duties of the job

• Undertake comprehensive and proportionate clinical assessments in patients homes and remotely.
• Assess, diagnose, prescribe and manage treatment within professional competence and agreed clinical pathways.
• Identify deterioration, falls risk, medicines issues, unmet long-term condition needs and wider social concerns.
• Develop and update personalised care plans, including escalation and anticipatory planning where appropriate.
• Review remote monitoring alerts and make timely clinical decisions, including home visits or onward referral.
• Work closely with GPs, the HCA, care coordinator, social workers, social prescribers and other community services.
• Maintain accurate contemporaneous records on EMIS and relevant digital systems.
• Contribute to clinical audit, quality improvement, incident learning and service development.
• Provide advice and support to less experienced team members within scope of practice.

Job description

Undertake comprehensive and proportionate clinical assessments in patients homes and remotely.

• Assess, diagnose, prescribe and manage treatment within professional competence and agreed clinical pathways.
• Identify deterioration, falls risk, medicines issues, unmet long-term condition needs and wider social concerns.
• Develop and update personalised care plans, including escalation and anticipatory planning where appropriate.
• Review remote monitoring alerts and make timely clinical decisions, including home visits or onward referral.
• Work closely with GPs, the HCA, care coordinator, social workers, social prescribers and other community services.
• Maintain accurate contemporaneous records on EMIS and relevant digital systems.
• Contribute to clinical audit, quality improvement, incident learning and service development.
• Provide advice and support to less experienced team members within scope of practice.

About us

The Primary Care Alliance (PCA) is the collaborative voice of general practice across the Berkshire West Place within the Thames Valley Integrated Care System. We bring together GP practices and Primary Care Networks (PCNs) to work at scale, enabling innovation, influencing system change, and delivering services that meet the needs of our local populations.

PCA plays a vital role in shaping the future of primary care by strengthening partnerships, developing the workforce, and ensuring general practice is a central and equal partner in integrated care. As a community interest company, PCA supports primary care sustainability, equity, and improved outcomes for patients across Reading, Wokingham, and West Berkshire.