Primary Care Network Frailty Practitioner

Kernow Health CIC; Saltash; Hybrid; GBP 32,000 - 42,000; Full time

Job summary

Kernow Health CIC in Cornwall is seeking a patient-facing clinician to support GP practices across Saltash, Torpoint, Liskeard and Looe. You will work to assess, coordinate and coordinate care for people living with frailty, helping prevent hospital admissions and supporting discharge planning.

The role involves hybrid working between home and GP practices, with travel across the locality and collaboration with multidisciplinary teams to ensure timely and safe care for patients.

Qualifications

• Substantial post-registration experience working with people living with frailty, multimorbidity or complex needs.
• Experience in holistic assessment, care planning and risk management.
• Ability to discuss complex matters with patients and professionals.

Responsibilities

• Provide timely assessment, intervention and care coordination for frail patients.
• Travel between Saltash, Torpoint, Liskeard and Looe areas to undertake home visits.
• Support practices through MDT meetings and avoid hospital admissions.
• Work across organisational boundaries with safeguarding and information governance.

Skills

Frailty knowledge

Clinical judgement

Care coordination

Multidisciplinary teamwork

Effective communication

Information governance

Safeguarding knowledge

Travel between sites

Education

NMC registered nurse

HCPC registered OT/Physiotherapist

Job description

This is a patient-facing role supporting GP practices across the Saltash and Torpoint, and Liskeard and Looe Integrated Neighbourhood Team areas. The postholder will work on a hybrid basis between home, GP practices and other health and care locations across these areas. Regular travel throughout the locality will be required. You will work with people living with frailty whose health, independence or functional ability has deteriorated, providing timely assessment, intervention and care coordination. The service supports practices through daily multidisciplinary team meetings, helps prevent avoidable hospital admissions and supports patients to return home safely following discharge. We welcome applications from registered nurses, occupational therapists and physiotherapists. Professional background is less important than strong frailty knowledge, sound clinical judgement and the ability to coordinate care across organisational boundaries. You must be registered with the Nursing and Midwifery Council as a registered nurse or with the Health and Care Professions Council as an occupational therapist or physiotherapist.

• Substantial post-registration experience working with people living with frailty, multimorbidity or complex needs.
• Experience of holistic assessment, care planning and clinical or functional risk management.
• The ability to recognise deterioration and make safe, timely decisions within your competence.
• Experience of effective multidisciplinary and cross-organisational working.
• Strong communication skills, including the ability to discuss complex and sensitive matters with patients, carers and professionals.
• Knowledge of adult safeguarding, consent, the Mental Capacity Act and information governance.
• The ability to prioritise and manage a complex community caseload.
• The ability to travel independently throughout the Saltash and Torpoint, and Liskeard and Looe areas and undertake home visits.
• Experience in primary care, community services, urgent response, hospital discharge or admission avoidance would be particularly valuable. An advanced clinical assessment, independent prescribing, frailty, rehabilitation or older peoples care qualification would be advantageous but is not essential. Independent prescribing would only form part of the role where it is relevant to the successful candidates professional background and agreed scope of practice.
• If you are an experienced clinician who understands frailty, can bring clarity to complex situations and is comfortable working across professional and organisational boundaries, we would like to hear from you.

East Cornwall PCN brings together seven GP practices serving communities across East Cornwall. Our teams work across practice and organisational boundaries to improve access, coordinate care and provide effective support for people with complex needs. This role is part of the PCNs reactive frailty service. Although the postholder will work closely with community and neighbourhood services, the roles core purpose is to provide responsive frailty support to practices and their patients.