I'm Kayleigh, the Clinical Lead Nurse Practitioner for the Patient Aligned Community Team (PACT), supporting patients with long-term and complex health conditions. My role focuses on helping patients access the right care and services, enabling them to manage their symptoms effectively and remain safe and independent in their own homes.

On a day-to-day basis, I assess and review patients with multiple long-term conditions, coordinate care plans, liaise with multidisciplinary teams, and make necessary referrals to community or specialist services.

Patients are referred to me via their GP practice, hospital discharge teams, community nursing teams, or through proactive case finding of high-risk or frequently attending patients.

My role focuses on admission avoidance and supporting safe discharge from hospital. By identifying early signs of deterioration and providing timely interventions, I help prevent unnecessary hospital admissions. This ensures patients can remain at home safely with the right support in place. I also help patients, and their families navigate health and social care services, improving access to specialist care and enhancing quality of life.

I support the GP practices by managing frail and elderly patients, frequent attenders, and those at high risk of hospitalisation. I work closely with GPs, practice nurses, and care coordinators to create individualised care plans, ensuring continuity and reducing the workload on GP teams. My role enhances practice resilience, reduces avoidable admissions, and enables other clinicians to focus on more complex or urgent cases.

The most rewarding part of my role is knowing that I can make a real difference to a patient’s life - whether by improving their quality of life, empowering them to manage their health, or ensuring they feel safe and supported at home. It’s incredibly fulfilling to see patients remain independent and to know that our input has helped them avoid hospital admissions and stay within their own community.

Dr Irfan Akram, Clinical Director of Southend West Central PCN:

This role has transformed the way we plan, organise and deliver patient care holistically in their own home.

Patients, relatives and GP practice staff have given outstanding feedback about Kayley’s positive impact in improving patients’ lives, and we are proud of the strong relationship the PCN has built with our Council, hospital and community colleagues through Kayley’s work.

Emma Tindall, Operations Manager, Southend West Central PCN:

Kayley delivers excellent care efficiently and works effectively as part of the multi-disciplinary team. She is a wonderful advocate for her patients and always has their needs at the forefront of her work.

The nature of her role means she is able to spend time with her patients to fully address their needs, time that GP practices may not be able to give. 

She has established a well-functioning frailty service and continues to drive improvements in its delivery. Her proactive approach and strong commitment to acting in the best interests of patients are evident in her daily practice.

Positive feedback from patients and their families reflects her compassionate and professional approach.

A typical case might involve an elderly patient with multiple long-term conditions such as COPD, diabetes, and heart failure, who has been frequently admitted to hospital. Following referral, I complete a comprehensive assessment at home, reviewing medication, mobility, nutrition, and social support. I coordinate with community physiotherapists, occupational therapists, and social care to ensure the right equipment and care are in place.

Through regular reviews and early intervention, the patient becomes more confident in managing their symptoms, avoids further hospital admissions, and remains safely at home with an improved quality of life.