Frailty Practitioner

Integrated Care System; Weymouth; On-site; GBP 17,000 - 23,000; Part time

Job summary

A leading healthcare organization in Weymouth seeks a committed Frailty Practitioner to join its community team. This part-time role focuses on enhancing care for frail patients, including home visits and working closely with a multidisciplinary team. Applicants must hold full registration with NMC/HCPC and possess essential clinical skills. Flexible hours with no unsociable shifts allow for a supportive work-life balance.

Qualifications

• Registered with NMC/HCPC plus Licence to Practise required.
• Demonstrable communication skills essential.
• Transport access for site visits necessary.

Responsibilities

• Conduct assessments and maintain treatment records for registered patients.
• Work with MDT to manage frail patients in care homes and housebound.
• Provide clinical management plans and follow-up care.

Skills

Clinical examination skills

Chronic disease management

Immunisation

ECG

Phlebotomy

Wound management

Education

Full Registration with NMC/HCPC

Job description

INTERVIEWS EXPECTED TO TAKE PLACE TUESDAY 29TH & WEDNESDAY 30TH JULY

Frailty Practitioner required to join a well established community team working to improve care for our frailer patients. The role covers the entire Primary Care Network (PCN) and involves working for all 5 surgeries, and as part of the wider Integrated Neighbourhood Team.

The Frailty Practitioner will join a team consisting of 3 GPs, 6 Frailty Nurses/Advanced Clinical Practitioners a Trainee ACP Occupational Therapist and a physiotherapist, with support from Frailty Assistant HCAs to proactively manage patients living in care homes, those who are housebound and in the 'Ageing Well clinic' to support earlier intervention. Admission avoidance, improved diagnostic rates, better coordination of care, increased use of anticipatory care plans, reduction in falls and improved management of chronic conditions are amongst the objectives.

We are looking for a committed and enthusiastic Frailty Practitioner to help provide high quality health care for this frail population. The role will be part time hours, up to 30 hours per week, but the days/times are negotiable (no unsociable hours). Support and clinical governance will be provided by the lead GP. Travel included.

This is Enhanced Nurse / Paramedic role- clinical examination skills are essential and prescribing is desireable. Chronic disease management, immunisation, ECG, phlebotomy and wound management skills preferred but not essential.

Main duties of the job

• To complete the requested assessments for registered patients allocated to the team and maintain appropriate records of treatment given and NHS services provided; When appropriate, make a relevant diagnosis and management plan, implement this plan and subsequently evaluate it
• Carry out consultations and physical assessments as requested, formulate a diagnosis, and maintain high quality contemporaneous records using SystmOne
• Make him/herself available to undertake visits to care and nursing homes and the housebound as requested, assessing patients, liaising with the service GPs or registered GP when the service GP(s) are not available. Attending MDT meetings where possible
• Liaise with other members of community teams, as appropriate to individual patient needs
• Arrange for the referral of patients when it is possible for the Frailty Practitioner to make the referral, otherwise defer the need for a referral back to the service GPs
• Note any possible issues with medication compliance identified during any patient contact
• Actively work with the wider MDT by working with, but not exclusively, the community matrons, community nurses, discharge co-ordinators, elderly care teams at Dorset County Hospital and community hospitals, dieticians, tissue viability team, CPN, CRT, physio, SALT, falls prevention services

About us

Two Harbours Healthcare is a not for profit organisation led by local General Practices in Weymouth and Portland. Our goal is to work more closely together (and with stakeholders) to share expertise, resources and provide services for the NHS.

Job responsibilities

Based on an integratedapproach, the Frailty Practitioner will join the existing team, working in anintegrated way with the wider MDT which currently exists in the locality toprovide a pro-active service for the frail population. The Frailty Practitioner willbe part of the primary healthcare multi-disciplinary team and will utilise theskills of the wider existing primary care team.

HouseboundPatients:

• Homevisits to identified patients to complete baseline assessments using anagreed proforma CGA template to include (but not exclusively) continence, skin,nutritional status, care needs and unmet needs.
• Referralof patients when appropriate to Frailty Assistants to collect additionalinformation or to complete additional assessments e.g., weight monitoring,BP checks, ECG, phlebotomy etc
• Followup visits to patients who are appropriate for the service (i.e., moderate,or severe frailty) to identify deterioration, chronic disease monitoring,referrals for newly identified needs
• Ensurepatients who are discharged from the service (mild frailty or less) areaware they can re-refer if deteriorating
• Makereferrals to the wider MDT (including third sector) if and whenappropriate
• Followingassessment and diagnosis; develop and communicate clinical management plans
• Liaisewith usual GP if assistance required for management strategies
• Workwith the lead GP to help develop a proactive review register ensuring thatLead GP is aware of patients assessed and outcome of assessments
• Manageown caseload of patients determine appropriate frequency for review, scheduleappointments
• Daysand hours to be negotiated, no unsociable hours required.
• Awarenessand understanding of the supporting document Housebound visiting modelspecification

CareHome Service

• Weeklyvisit to named care homes
• Toassist with cross cover within the team to ensure each care home receivesa weekly visit (following a set rota)
• Toassist with triage for acute care home visits (following a set rota)
• Reviewpatients as requested by the care home, by task from Lead GP or other colleagues,monitor patients for deterioration, chronic disease monitoring
• Makereferrals to the wider MDT (including third sector) if and whenappropriate
• EnsureLead GP is notified of all new patients
• Formulatediagnosis, develop, and communicate clinical management plans
• Liaisewith Lead GP if assistance required for management strategies
• Identifypatients approaching end of life, support care home with planning, prescribeanticipatory palliative medication, liaise with Lead GP for face-to-facereview.
• Awarenessand understanding of the supporting document Care Home visiting modelspecification
• Verificationof Life Extinct

Forall patients

• AdvanceCare Planning discussion to include discussion about resuscitation status
• Completionof the Dorset Care Plan
• Completionof Allow a Natural Death Form when appropriate
• Ensureawareness of recall system and when reviews are due, follow-on recalls andensure all relevant monitoring is completed
• HolisticMedication review
• Prescribingand appropriate adjustments of medication with appropriate monitoring

Other

• Attendanceat surgery MDT meetings if requested to do so
• Ensurework emails are regular accessed
• Ensurework mobile is carried at all times and that messages are picked up atregular intervals through the working day
• Interpretdata from various sources e.g., frailty data, MDT data, frailty registersto determine which patients would benefit from holistic review when requestedto do so
• AssistLead GP when requested to develop service

Person Specification

Personal Qualities

• All applicants to have demonstrable skills in written and spoken English that are adequate to enable effective communication about medical topics with patients and colleagues. Must have access to a means of transport to facilitate movement between sites.

Qualifications

• Hold Full Registration with the NMC/HCPC plus Licence to Practise

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.