Job summary
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 description
Job responsibilities
Based on an integrated
approach, the Frailty Practitioner will join the existing team, working in an
integrated way with the wider MDT which currently exists in the locality to
provide a pro-active service for the frail population. The Frailty Practitioner will
be part of the primary healthcare multi-disciplinary team and will utilise the
skills of the wider existing primary care team.
Housebound
Patients:
- Home
visits to identified patients to complete baseline assessments using an
agreed proforma CGA template to include (but not exclusively) continence, skin,
nutritional status, care needs and unmet needs.
- Referral
of patients when appropriate to Frailty Assistants to collect additional
information or to complete additional assessments e.g., weight monitoring,
BP checks, ECG, phlebotomy etc
- Follow
up 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
- Ensure
patients who are discharged from the service (mild frailty or less) are
aware they can re-refer if deteriorating
- Make
referrals to the wider MDT (including third sector) if and when
appropriate
- Following
assessment and diagnosis; develop and communicate clinical management plans
- Liaise
with usual GP if assistance required for management strategies
- Work
with the lead GP to help develop a proactive review register ensuring that
Lead GP is aware of patients assessed and outcome of assessments
- Manage
own caseload of patients determine appropriate frequency for review, schedule
appointments
- Days
and hours to be negotiated, no unsociable hours required.
- Awareness
and understanding of the supporting document Housebound visiting model
specification
Care
Home Service
- Weekly
visit to named care homes
- To
assist with cross cover within the team to ensure each care home receives
a weekly visit (following a set rota)
- To
assist with triage for acute care home visits (following a set rota)
- Review
patients as requested by the care home, by task from Lead GP or other colleagues,
monitor patients for deterioration, chronic disease monitoring
- Make
referrals to the wider MDT (including third sector) if and when
appropriate
- Ensure
Lead GP is notified of all new patients
- Formulate
diagnosis, develop, and communicate clinical management plans
- Liaise
with Lead GP if assistance required for management strategies
- Identify
patients approaching end of life, support care home with planning, prescribe
anticipatory palliative medication, liaise with Lead GP for face-to-face
review.
- Awareness
and understanding of the supporting document Care Home visiting model
specification
- Verification
of Life Extinct
For
all patients
- Advance
Care Planning discussion to include discussion about resuscitation status
- Completion
of the Dorset Care Plan
- Completion
of Allow a Natural Death Form when appropriate
- Ensure
awareness of recall system and when reviews are due, follow-on recalls and
ensure all relevant monitoring is completed
- Holistic
Medication review
- Prescribing
and appropriate adjustments of medication with appropriate monitoring
Other
- Attendance
at surgery MDT meetings if requested to do so
- Comprehensive
record keeping on SystmOne
- Ensure
work emails are regular accessed
- Ensure
work mobile is carried at all times and that messages are picked up at
regular intervals through the working day
- Interpret
data from various sources e.g., frailty data, MDT data, frailty registers
to determine which patients would benefit from holistic review when requested
to do so
- Assist
Lead GP when requested to develop service
Job description
Job responsibilities
Based on an integrated
approach, the Frailty Practitioner will join the existing team, working in an
integrated way with the wider MDT which currently exists in the locality to
provide a pro-active service for the frail population. The Frailty Practitioner will
be part of the primary healthcare multi-disciplinary team and will utilise the
skills of the wider existing primary care team.
Housebound
Patients:
- Home
visits to identified patients to complete baseline assessments using an
agreed proforma CGA template to include (but not exclusively) continence, skin,
nutritional status, care needs and unmet needs.
- Referral
of patients when appropriate to Frailty Assistants to collect additional
information or to complete additional assessments e.g., weight monitoring,
BP checks, ECG, phlebotomy etc
- Follow
up 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
- Ensure
patients who are discharged from the service (mild frailty or less) are
aware they can re-refer if deteriorating
- Make
referrals to the wider MDT (including third sector) if and when
appropriate
- Following
assessment and diagnosis; develop and communicate clinical management plans
- Liaise
with usual GP if assistance required for management strategies
- Work
with the lead GP to help develop a proactive review register ensuring that
Lead GP is aware of patients assessed and outcome of assessments
- Manage
own caseload of patients determine appropriate frequency for review, schedule
appointments
- Days
and hours to be negotiated, no unsociable hours required.
- Awareness
and understanding of the supporting document Housebound visiting model
specification
Care
Home Service
- Weekly
visit to named care homes
- To
assist with cross cover within the team to ensure each care home receives
a weekly visit (following a set rota)
- To
assist with triage for acute care home visits (following a set rota)
- Review
patients as requested by the care home, by task from Lead GP or other colleagues,
monitor patients for deterioration, chronic disease monitoring
- Make
referrals to the wider MDT (including third sector) if and when
appropriate
- Ensure
Lead GP is notified of all new patients
- Formulate
diagnosis, develop, and communicate clinical management plans
- Liaise
with Lead GP if assistance required for management strategies
- Identify
patients approaching end of life, support care home with planning, prescribe
anticipatory palliative medication, liaise with Lead GP for face-to-face
review.
- Awareness
and understanding of the supporting document Care Home visiting model
specification
- Verification
of Life Extinct
For
all patients
- Advance
Care Planning discussion to include discussion about resuscitation status
- Completion
of the Dorset Care Plan
- Completion
of Allow a Natural Death Form when appropriate
- Ensure
awareness of recall system and when reviews are due, follow-on recalls and
ensure all relevant monitoring is completed
- Holistic
Medication review
- Prescribing
and appropriate adjustments of medication with appropriate monitoring
Other
- Attendance
at surgery MDT meetings if requested to do so
- Comprehensive
record keeping on SystmOne
- Ensure
work emails are regular accessed
- Ensure
work mobile is carried at all times and that messages are picked up at
regular intervals through the working day
- Interpret
data from various sources e.g., frailty data, MDT data, frailty registers
to determine which patients would benefit from holistic review when requested
to do so
- Assist
Lead GP when requested to develop service
Person Specification
Personal Qualities
Essential
- 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
Essential
- Hold Full Registration with the NMC/HCPC plus Licence to Practise
Person Specification
Personal Qualities
Essential
- 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
Essential
- 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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Additional information
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
