Admission Prevention Nurse
| Company: | NHS Jobs |
|---|---|
| Salary: | £22 to £26 an hour |
| Hours: | Full-time |
| Location: | Birkenhead, CH49 7LP |
| Job type: | Contract |
| Posting date: | 7 Oct 2026 |
| Closing date: | 19 Oct 2026 |
Summary
Key Responsibilities Proactive Case Finding and Admission Prevention Use available population health, risk-stratification and clinical information to identify patients at greatest risk of deterioration and unplanned hospital admission. Maintain a particular focus on the PCN's highest-risk cohort, including patients identified within the top 1% risk of admission. Accept and clinically triage referrals from GPs, PCN clinicians, community teams and other appropriate neighbourhood partners. Proactively contact patients rather than relying solely on patients presenting to services when their health has deteriorated. Identify emerging deterioration, unmet need and modifiable risk factors at the earliest opportunity. Develop individualised plans aimed at maintaining patients safely within their usual place of residence wherever clinically appropriate. Identify recurrent patterns of emergency department attendance, hospital admission or crisis and work with patients, families and professionals to address potentially preventable causes. Advanced Clinical Assessment Undertake comprehensive and holistic assessment of patients with complex health and care needs within their own homes, GP practices and other appropriate community settings. Assess physical health, frailty, functional ability, cognition, medication, nutrition, falls risk, social circumstances and other factors affecting a patient's ability to remain well at home. Recognise signs of acute deterioration and exercise autonomous clinical judgement regarding appropriate intervention and escalation. Undertake relevant clinical observations and assessments within professional competence. Identify red flags requiring urgent medical assessment or escalation and act appropriately. Develop and review personalised care and support plans in partnership with patients, carers and other professionals. Support anticipatory care planning for patients at increased risk of deterioration or crisis. Clinical Intervention and Management Provide nursing interventions within the postholder's professional competence to prevent deterioration and support recovery at home. Monitor patients following episodes of deterioration and provide appropriate short-term enhanced support where this may prevent escalation to hospital. Support optimisation of long-term conditions in collaboration with the patient's GP and relevant specialist services. Undertake medication review and medicines-related assessment within professional competence, working closely with GPs, PCN pharmacists and other prescribers. Identify and address factors contributing to poor health outcomes, including adherence, nutrition, hydration, mobility, falls, social isolation and ability to self-manage. Provide education and advice to patients and carers to improve recognition of deterioration and support appropriate self-management. Working within the wider PCN nursing team when required to support general nursing work including seasonal vaccination. Ensure appropriate safety-netting and escalation arrangements are in place. Care Coordination and Neighbourhood Working Act as a key clinical coordinator for patients whose complexity requires input from multiple services. Work collaboratively with general practice, community nursing, frailty services, social care, pharmacy, mental health, therapy services, secondary care and voluntary/community organisations. Participate actively in PCN and neighbourhood multidisciplinary team meetings. Ensure that patients are connected with existing services wherever these can appropriately meet identified needs, avoiding unnecessary duplication. Facilitate rapid communication between services where deterioration or emerging risk is identified. Support effective transfer of care following hospital discharge where early intervention may reduce the risk of readmission. Develop effective professional relationships across organisational boundaries to support increasingly integrated neighbourhood working. Identify gaps, duplication and barriers within existing pathways and contribute to developing more effective admission-prevention pathways. Personalised and Preventative Care Place the patient and their individual goals at the centre of assessment and care planning. Support patients to maintain independence and remain within their preferred place of care wherever safe and appropriate. Take a strengths-based approach, recognising the capabilities of patients, carers and their wider support networks. Identify opportunities for prevention and early intervention rather than responding only once a patient reaches crisis. Recognise wider determinants affecting a patient's health and ability to remain well at home and facilitate access to appropriate support. Promote shared decision-making and support patients to make informed decisions about their care. Clinical Leadership Provide visible clinical leadership for proactive admission prevention within the PCN. Act as a senior clinical resource for colleagues managing patients at high risk of admission. Promote a proactive rather than reactive approach to the management of complex and vulnerable patients. Support the development of effective pathways between primary care, community services and secondary care. Provide professional advice and education to PCN colleagues within the postholder's areas of expertise. Contribute to the development of the PCN's wider proactive care, frailty and neighbourhood strategy. Support the development of a culture in which admission prevention is viewed as a shared responsibility across the neighbourhood multidisciplinary team. Act as a PCN representative at meetings, stakeholder events and community engagement initiatives. As a developing model of care, demonstrating the impact of the service will be a key responsibility of the postholder. Data contribute to establishing baseline measures and outcome indicators for the service. maintain accurate activity, coding and outcome data. monitor interventions and patient outcomes. contribute to audit and quality-improvement activity with the support of the digital transformation lead. review patterns of admission and urgent care utilisation within the target cohort; identify learning from cases where admission was successfully avoided and where patients subsequently required hospital care. obtain and respond to patient, carer and professional feedback; contribute to regular evaluation and refinement of the service model; and provide reports and case studies demonstrating service activity, outcomes and learning.