Advanced Care Practitioner - Frailty

Lowther Medical Centre; Midsomer Norton; On-site; GBP 45,000 - 65,000; Full time

Job summary

Lowther Medical Centre is seeking an Advanced Care Practitioner to join its Frail Elderly Assessment Team (FEAT) within the PCN. The role focuses on autonomous clinical practice delivering high-quality, patient-centered care to frail individuals in their homes and in care homes.

The post holder will manage frailty, dementia and end-of-life care, assess and treat patients without direct input from a physician, and work closely with GPs, OTs, Physios, Social Prescribers and Community Nursing Team.

Qualifications

• Advanced clinical assessment and management of frailty
• Ability to diagnose and manage complex conditions in home care settings
• Strong collaboration with GPs, therapists and social care teams

Responsibilities

• Deliver high-quality patient-centered care in patients' homes and care homes
• Provide advanced clinical decision making within scope of practice
• Coordinate care with multi-disciplinary teams and Community Nursing Team
• Identify and manage palliative needs and advanced care planning
• Lead and participate in weekly care home reviews and MDT meetings

Skills

Advanced clinical skills

Frailty care

Home visits

Autonomous practice

NMC registered

Education

Advanced Nursing/Master's in Frailty

Job description

We are looking for a motivated and experienced Advanced CarePractitioner to join our PCN and work within our Frail Elderly Assessment Team(FEAT). This is an exciting opportunity to deliver high qualitypatient-centered care to frail patients in their own homes and in our carehomes.

The role combines autonomous practice, care coordination,multi-agency collaboration, management of increasing frailty, dementia and endof life care.

The postholder will work at an advanced level of clinicalpractice, exercising a high degree of professional autonomy and accountabilitywhile working within the NMC code and national ACP frameworks.

Main duties of the job

Work using FEAT and champion evidence-base interventions

Monitor medication use and adjust treatment plans asrequired

Exercise advanced clinical reasoning to diagnose, treat, andmanage patients without direct input from a medical practitioner, recognisingown professional boundaries and seeking senior clinical support when required.

Provide expert management of frailty syndromes

Identify when clinical presentations fall outside of scopeof practice and elevate appropriately to senior clinicians.

Work closely with GPs, OTs, Physios, Care Co-ordinators,Social Prescribers and Community Nursing Team

Attend the MDT meetings and case reviews

Support patients and families

Promote lifestyle self management strategies to optimisehealth and independence

Carry out clinical decision making such as diagnosing

Completing proactive clinical management plans for care homeresidents

Identify patients in need of palliative support andfacilitate advanced care planning discussions with patients and families

Communicating and caring for patients who have reducedunderstanding and insight

Participate in weekly enhanced care home reviews

Undertake daily acute care home visits identifying clinicalemergencies or deteriorating patients, ensuring appropriate action

Participate in regular clinical supervision and reflectiondiscussions

About us

NCPC (North Cumbria Primary Care) was established in August2019 in response to an increasingly fragile general practice provision withinNorth Cumbria. NCPCs vision is to bring practices together to develop asustainable, fully integrated primary care- built locally and deliveredtogether.

The Copeland NCPC area consists of 3 major practices,Fellview Health Care, Lowther Medical Centre and Seascale Health Centre as wellas a shared PCN (Primary Care Network) which delivers services to patientsacross all 3 practices.

We are a not-for-profit company with all money we receive infunding and other business activities going towards supporting theorganisation, our staff, and our services

Job responsibilities

Main Duties and Responsibilities

Work using FEAT and champion evidence-base interventions

Monitor medication use and adjust treatment plans asrequired, autonomously working within scope of practice and in line withprescribing competencies.

Exercise advanced clinical reasoning to diagnose, treat, andmanage patients without direct input from a medical practitioner, recognizingown professional boundaries and seeking senior clinical support when required.

Provide expert management of frailty syndromes, dementia,delirium, polypharmacy, falls risk and end of life needs.

Escalate concerns appropriately and initiate urgent oremergency interventions when required.

Identify when clinical presentations fall outside of scopeof practice and elevate appropriately to GP or senior clinicians.

Work closely with GPs, Occupational Therapists,Physiotherapists, Care Co-ordinators, Social Prescribers and Community NursingTeam

Attend the MDT meetings and case reviews

Support patients and families in understanding and managingfrailty

Promote lifestyle and self management strategies to optimisehealth and independence

Functions at a high level to carry out clinical decisionmaking such as diagnosing and managing patients without input from a medicalpractitioner remaining within scope of a professional practice.

Functions at a high level in relation to communicationskills through patient consultation and nursing assessment of physical,psychological and social needs.

Completing proactive, individualised clinical managementplans for care home residents improving their health experience and reducingunnecessary and potentially harmful hospital admissions

Identify patients in need of palliative support andfacilitate advanced care planning discussions with patients and families

Communicating with distressed/anxious/worried patients andrelatives

Caring for patients and relatives following receipt of badnews and supporting them in identifying realistic expectations in relation toclinical conditions

Communicating and caring for patients who have reducedunderstanding and insight due to cognitive impairments

Participate/lead weekly enhanced care home reviews

Undertake daily acute care home visits requested through ourclinical triage system identifying clinical emergencies, deteriorating patientsor patients at risk of deterioration ensuring appropriate action

Participate in regular clinical supervision, reflectivepractice and case-based discussions to maintain safe, effective and autonomouspractice.

Confidentiality:

In the course of seeking treatment, patients entrust uswith, or allow us to gather, sensitive information in relation to their healthand other matters. They do so in confidence and have the right to expect thatstaff will respect their privacy and act appropriately.

In the performance of the duties outlined in this JobDescription, the post-holder may have access to confidential informationrelating to patients and their carers, Practice staff and other healthcareworkers. They may also have access to information relating to the Practice as abusiness organisation. All such information from any source is to be regardedas strictly confidential.

Information relating to patients, carers, colleagues, otherhealthcare workers or the business of the Practice may only be divulged toauthorised persons in accordance with the Practice policies and proceduresrelating to confidentiality and the protection of personal and sensitive data

Health & Safety:

The post-holder will assist in promoting and maintainingtheir own and others health, safety and security as defined in the practiceHealth & Safety policy, the practice Health & Safety manual, and thepractice Infection Control policy and published procedures. This will include:

Using personal security systems within the workplaceaccording to practice guidelines

Identifying the risks involved in work activities andundertaking such activities in a way that manages those risks

Making effective use of training to update knowledge andskills

Using appropriate infection control procedures, maintainingwork areas in a tidy and safe way and free from hazards

Actively reporting of health and safety hazards andinfection hazards immediately when recognised

Keeping own work areas and general / patient areas generallyclean, assisting in the maintenance of general standards of cleanlinessconsistent with the scope of the job holders role

Undertaking periodic infection control training (minimumannually)

Equality and Diversity:

The post-holder will support the equality, diversity andrights of patients, carers and colleagues, to include acting in a way thatrecognizes the importance of peoples rights, interpreting them in a way that isconsistent with Practice procedures and policies, and current legislation.Respecting the privacy, dignity, needs and beliefs of patients, carers andcolleagues. Behaving in a manner which is welcoming to and of the individual,is non-judgmental and respects their circumstances, feelings priorities andright.

Personal/Professional Development:

The post holder will participate in all training programmesimplemented by the Practice, including annual performance reviews andcompetency assessments, and will take responsibility for their own ongoingdevelopment, learning and performance.

They will maintain a comprehensive professional portfoliodemonstrating autonomous clinical practice, clinical supervision, CPD andreflective learning, ensuring that clinical competencies required for safeautonomous practice in frailty care are continually met.

The post holder will contribute to clinical governanceactivities such as audits, incident reviews and quality improvementinitiatives, while engaging in regular clinical supervision and reflectivediscussions to support safe, accountable practice. They will also support thedevelopment of colleagues by sharing specialist frailty knowledge, offeringmentorship and demonstrating skills and activities to others undertakingsimilar work

Quality:

The post-holder will strive to maintain quality within thePractice and will assess own performance and take accountability for ownactions, either directly or under supervision. Contribute to the effectivenessof the team by reflecting on own and team activities and making suggestions onways to improve and enhance the teams performance. Work effectively withindividuals in other agencies to meet patients needs. Effectively manage owntime, workload and resources

Communication:

The post-holder should recognise the importance of effectivecommunication within the team and will strive to communicate effectively withother team members, communicate effectively with patients and carers andrecognise peoples needs for alternative methods of communication and respondaccordingly.

Person Specification

• Essential: Advanced clinical masters degree. Practice Registered Nurse on the NMC register. Non-medical prescriber. Demonstrate high level of competence/advanced skills in clinical examination and diagnosis Interpret pathology/radiology results/reports and action where appropriate. Excellent interpersonal and communication skills, providing enhanced discussions with patients and families regarding end of life wishes/planning Familiar with the complex geriatric assessment, 4AT, GPCOG Knowledge in EMIS clinical system Knowledge of the Accurx system Effective time management skills Advanced communication skills Ability to work as an autonomous Practitioner Able to work on own initiative Must be personable, polite and approachable Must be a team player Must be adaptable to change Commitment to ongoing training and education to develop clinical skills Have the ability to prioritise workload Able to work under pressure and remain calm Full clean driving licence
• Desirable: Specialist knowledge within frailty Experience of working in a primary care setting would be beneficial Experience of working with frail/elderly patients at an advanced level

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.