Frailty Clinical Practitioner

Job summary Exciting opportunity to join an enthusiastic and good-humoured Primary Care Network Frailty Care Team looking for a like minded Frailty Clinical Practitioner to join our team.
To work as an autonomous practitioner, providing expert clinical case management for people with frailty with intensive, chronic, transitory and sometimes acute biopsychosocial needs who are at risk of increased loss of independence that may results in loss of quality of life, avoidable hospital admission or unnecessary length of stay.
As a Frailty Clinical Practioner and Idependant prescriber your role will be crucial in preventing increased loss of independence, avoiding unnecessary hospital admissions and supporting the Frailty Care Team in the delivery of the Enhanced Care in Care Homes contract for the PCN.
You will manage of caseload of individuals identified as needing support to improve or maintain their quality of life and undertake weekly care home ward rounds idependently.
You will be part of an exciting and innovative quality improvement project with a support MDT in the beautiful setting of the North Cotswolds.
Main duties of the job Main dutiesTo provide expert clinical case management for people with frailty who may have multiple long-term conditions and are at risk of deteriorating health that may result in declining clinical quality of life or avoidable hospital admission, or unnecessary length of hospital stayTo undertake the weekly care home and nursing home GP ward rounds across the North Cotswold PCN care home group.Develop relationships with staff within the neighbourhood team including practices, ICT, Older Peoples Mental Health service, Rapid Response and adult social care collaborating with them on a day-to-day basis.Undertake comprehensive geriatric assessment of the physical, functional and psycho-social care needs of people with frailty who may also have complex chronic conditions.
This will involve using a single assessment process, gathering and interpreting information, carrying out and requesting investigations and analysing and taking appropriate action for the results alongside and with the support of MDT colleagues and neighbourhood teams.Develop a person led evidence-based holistichealth and social care plan in conjunction with patients and their relativesand carers, medical and other health and social care colleagues.
About us About North Cotswold PCNNorth Cotswold Primary Care Network is an NHS collaboration between 5 GP Practices, all with a CQC overall good rating - Chipping Campden Surgery, Cotswold Medical Practice, Mann Cottage Surgery, Stow Surgery and The White House Surgery.
Our surgery teams are working closely with each other, enjoying the ability to share expertise and resources, to develop new services.
Our vision is to continue to improve the quality of care that we provide in alignment with the need of our patient population.
As part of a PCN we are able to take advantage of additional staff roles that are now available to support all of our patients.
Our Frailty Care Team is a multi disciplinary team of ANPs, Clinical Pharmacists, Community matrons, Health and Wellbeing Coaches and Care Coordinators currently using a quality improvement approach to improve care and services to the population on our frailty case load which includes patients in care and nursing homes across the PCN locality.
This is an exciting opportunity to join our team and support the patients in our care home setting and in their own homes.
Job description Job responsibilities Job description (including main duties above) To provide expert clinical case management for people with frailty who may have multiple long-term conditions and are at risk of deteriorating health that may result in declining clinical quality of life or avoidable hospital admission, or unnecessary length of hospital stay To undertake the weekly care home and nursing home GP ward rounds across the North Cotswold PCN care home group.
Supporting and working with close family, carers and wider family members Develop relationships with staff within the neighbourhood team including practices, ICT, Older Peoples Mental Health service, Rapid Response and adult social care collaborating with them on a day-to-day basis.
Undertake comprehensive geriatric assessment of the physical, functional and psycho-social care needs of people with frailty who may also have complex chronic conditions.
This will involve using a single assessment process, gathering and interpreting information, carrying out and requesting investigations and analysing and taking appropriate action for the results alongside and with the support of MDT colleagues and neighbourhood teams.
Develop a person led evidence-based holistic health and social care plan in conjunction with patients and their relatives and carers, medical and other health and social care colleagues.. Prioritise individuals for assessment and management according to their health status and needs, referring for specialist assessment, diagnostic tests and programmes of support as appropriate.
Establish and maintain excellent communication with individuals and groups, exploring complex issues relating to care options and decisions and sustain effective working relationships across all health and social care service organisations.
Use a high level of communication and interpersonal skills to communicate effectively with patients and carers, in particular the skills needed for cognitive assessment and mental health status.
Refer individuals to mental health and/or other services where appropriate.
Enable individuals to access psychological support.
Ensure patients needing palliative care or End of Life Care receive high quality care aligned to the Gloucestershire End of Life Strategy and NICE Clinical Guidelines.
Challenge prejudice and inequalities in access to mainstream provision for individuals with frailty and may have long term conditions.
Establish effective working relationships with people, their families and carers.
This will include promoting individual rights and recognising and respecting their ability to co-produce care plans and associated delivery.
Interpret and discuss assessment outcomes with people, carers, the PCN MDT members and other health and social care professions and the voluntary sector.
Work with people and carers to inform and educate about the early warning signs in order to facilitate rapid management of complications or crises.
Enable people to be as independent as possible by facilitating a range of self-management strategies through undertaking desired occupations and non- occupational activities including the support that is available from the voluntary sector.
Monitor quality and effectiveness of clinical care for people with frailty through audit and research.
Contribute to the audit process in relation to user expectations, appropriateness and effectiveness of the service and continuous improvement.
Work effectively with Practices, Care Homes and Nursing Homes, local health, social care, housing and voluntary sector services.
Collaborate with service providers, people and carers to develop and review integrated patient pathways.
Challenge existing knowledge, current poor practice and be open to be challenged by others.
Constantly strive to identify training needs for self and support others.. To fulfil the requirements for maintaining a professional registration.
The post holder is expected to adhere to local policy and procedures Work across professional and where appropriate, organizational boundaries developing and sustaining new partnerships and networks to influence and improve health outcomes and health care delivery systems.
Be responsible for participating in weekly/monthly MDTs in GP practice, Frailty Care Team, Geriatrician Meeting, Ward rounds, Community Dementia Team, Practice GSF/Frailty meetings.
Communicate detailed clinical information when referrals are made to the multidisciplinary team to ensure that any examinations or tests to be done or samples that are required to be taken will capture the necessary facts to support the decision making of diagnosis and treatments.
Ensure that relevant colleagues are kept informed of the clinical progress of patients.
Discuss diagnosis, short term and long term, treatments and plans for patients in the area of responsibility, managing conflicting view, reconciling professional differences of opinion to facilitate optimum patient care.
Communicate (often complex) emotive and upsetting diagnoses and prognoses related information to patients, their families and or carers with tact, diplomacy and at times caution depending on the nature of the information to be conveyed.
Provide formal and informal presentations to staff groups as necessary and facilitate case based discussions for learning purposes.
Effectively managing patient information and analysing of data from a clinical perspective.
Establish communication networks with Frailty Care Team, GPs, specialist nurses/therapists and social workers to share good practice.
provide expert clinical case management for people with frailty who may have multiple long-term conditions and are at risk of deteriorating health that may result in declining clinical quality of life or avoidable hospital admission or unnecessary length of hospital stay.
proactively assess and monitor people on the caseload, identifying the early symptoms of frailty, disease exacerbation, acute illness and injuries.
Improve clinical outcomes for patients with frailty by enabling them to function independently by increasing their choice to remain in their own home/care home/nursing home/community and reduce the need for or prevent acute unplanned care hospital admission, out of hours or paramedic attendance.
Initiate and lead medicine management, reviews of medication and prescribe medicine and appliances for people via independent prescribing arrangements.
Investigate and diagnose an unwell individual with frailty who may have long term conditions.
Work proactively with people with frailty and their families to plan for and improve end of life care, ensuring that choices are reflected in personalised care plans and communicate with others involved in their care.
Continually develop an extensive knowledge of frailty and long term conditions and management and educate, support and advise groups and individuals on best practice.
Demonstrate a high level of clinical judgement, acting autonomously in a variety of contexts, in primary care settings and ensuring that patients are referred for medical assessment and diagnostic procedures when needed or if care is not within own scope of practice or competency.
Work within the Standards of Conduct, performance and ethics and any other policy guidance which informs and safeguards practice, professional conduct or professional identity.Encourage friends and family feedback and actively reflect and learn from feedback received, sharing successes and challenges with the wider frailty locality service for learning and development.
Engage with the incident or near miss reporting systems within the organisation and ensure staff within the team are supported to implement these processes and have an understanding of the mechanism which underpin such risk management approaches.
Provide and receive clinical supervision in order to continuously improve the quality of care to patients with frailty.
Use evaluation techniques including clinical audit to monitor the impact of the service on quality of care and cost effectiveness.
Organise own time effectively and efficiently in line with agreed job plan.
Support the delivery and MDT approach, working to support the common goal of safe, efficient high quality care delivery.
Chair meetings related to service delivery or case management for individuals or groups of people with frailty.
Deliver high quality care to people with frailty and their families using appropriate documentation and record keeping.
Adopt and promote the culture which embraces our core values and behaviours.
Actively participate in practice and service development and help identify areas requiring review and development and support ongoing quality improvement objectives of the North Cotswold Frailty Care Team Participate in staff survey and feedback mechanisms.
Ensure data collection is maintained and available in accordance with organisational policy and requirements.
Most Challenging Part of the Job The post holder may be required to work in any part of the organisation in line with service needs.
May be required to work flexibly across teams to ensure service delivery and safety.
Responsible for the maintenance and delivery of the service within their area of responsibility.
Identifies need for, leads and participates in, research projects/clinical trials as appropriate.
In consultation with Frailty Care Team Lead, agrees to undertake any other duties required for which he/she has adequate training and for which he/she is competent.
Person Specification Other attributes Essential Ability to develop and maintain effective working relationships with colleagues and other partners.
Ability to work autonomously with clear recognition of own limitations and when to seek advice MDT approach to management of complex patients Ability to work flexibly Driving Keyboard skills Must be proficient in clinical skills required for area of practice Desirable Knowledge of North Cotswolds area Experience Desirable Experience of working in primary care Experience of working in community team Qualifications Essential Educated to Degree level or equivalent competencies in health-related subjects Registered Professional Body Advanced Physical Assessment & Clinical Reasoning modules/course Independent Prescriber Qualification Knowledge in managing patients with complex medical needs, long term conditions management and palliative care Knowledge of current and emerging health and social care economy specifically the social care agenda Knowledge of governance and risk strategies and their application in a community setting Desirable Frailty competency broad experience working with elderly frail patients across pathway Knowledge of clinical systems SystmOne and/or EMIS Previous experience of working in primary care setting