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 e.g. 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.