Job summary
The Post Holder will be a highly competent
health care professional, accountable for your own actions and responsible for
providing enhanced evidence based nursing care and case management for patients
with frailty issues / long-term conditions.
The Enhanced Frailty Practitioner will provide
clinical support to patients, supported by the wider Clinical team, to work
autonomously holding their own caseload. Primary care provision rapidly changes
and the role is expected to evolve to reflect this.
You will be performance managed with clear
appraisals designed to evidence your success in delivering excellent patient
satisfaction and health outcomes, supporting the Frailty Team patient caseload,
developing colleagues skills, and lastly supporting patients avoid unnecessary
hospital admissions.
To provide integrated, pro-active care for people in Harrow aged 65
years of age or over, or identified as frail, with multiple complex long term
conditions, who require more intensive support and care in the community
To reduce avoidable hospital admissions / re-admission or A&E
attendances
To support Harrow GPs with intensive
case management of these more complex, vulnerable patients to
improve the health and wellbeing of patients by providing proactive, responsive
and intensive case management.
Main duties of the job
Actively
network with Practice Frailty Practitioners in Harrow to share andimplement best
practice and support case finding for the Harrow Enhanced Frailty Service.
Support
the Enhanced Frailty Team in the delivery of Complex Care.
To
maintain excellent working relationships with all those involved in the
provision and development of services for those with long term conditions.
Attend
all mandatory meetings such as Touch Point meetings and MDTs.
Managing Patients with Frailty issues
Identify,
assess and signpost patients on the Frailty Team list with complex long term
conditions, and nursing needs, in conjunction with GPs, district and specialist
nurses and other lead clinicians.
Develop
disease care management plans including self-care strategies to meet
individuals complex health and nursing needs
Provide
highly specialist care and advice - this could include diagnosis, management / treatment
plans and referrals as appropriate.
Manage
patients medicines and ensure adherence, in conjunction with GPs, consultants
and specialist nurses ensuring approaches are consistent with standards,
protocols and legislation
Working
closely with the Health and Social Care Coordinator to ensure patients have
relevant referrals and access in place to Harrow Community Services, attend and
liaise with the Frailty Team MDT groups, regularly attending case conferences
and providing relevant updates.
About us
Harrow Health CIC began in 2007 by a group of
Harrow GPs, whose sole aim was to ensure patients receive a high quality
clinical care service within the community. Over the years, HHCIC has expanded.
We now provide many clinical services, which include Primary Care Services,
Community Services, and our Whole Systems Integrated Care Services.
Our Vision:
To provide high quality patient care, enhancing
patient experience by providing excellent clinical effectiveness in a safe
environment; working in partnership to provide gold standard services and
develop a sustainable future for the local health community.
Job description
Job responsibilities
Main Responsibilities
Work
in accordance with the National and Midwifery Council (NMC) Code of Conduct for
Nurses / Health Care Professionals Council / General Pharmaceutical Council and
Scope of Professional Practice
Actively network with Harrow Enhanced Practitioners to share and implement best practice and support case finding for the Harrow Frailty Service
Support the Enhanced Frailty Team in the delivery of Complex Care.
To maintain excellent working relationships with all those involved in the provision and development of services for those with long term conditions.
Attend all mandatory meetings such as Touch Point meetings and MDTs.
Managing Patients with Frailty issues
Identify, assess and signpost patients on the Frailty Team list with complex long term conditions, and nursing needs, in conjunction with GPs, district and specialist nurses and other lead clinicians.
Develop disease care management plans including self-care strategies to meet individuals complex health and nursing needs
Provide highly specialist care and advice - this could include diagnosis, management / treatment plans and referrals as appropriate.
Manage patients medicines and ensure adherence, in conjunction with GPs, consultants and specialist nurses ensuring approaches are consistent with standards, protocols and legislation
Working closely with the Health and Social Care Coordinator to ensure patients have relevant referrals and access in place to Harrow Community Services, attend and liaise with the Frailty Team MDT groups, regularly attending case conferences and providing relevant updates
Communication Skills
The post-holder will recognize the importance of effective communication within the team and will strive to:
Utilise and demonstrate sensitive communication styles to ensure patients are fully informed, and consent to treatment.
Communicate highly sensitive patient information and progress effectively with other team members and outside relevant health and social care providers, including discussion with patient about ceilings of care, urgent care plans, end of life etc.
Communicate with patients in a welcoming way, which is non-judgemental and respects patients feelings, circumstances and rights.
Ensure all documented notes are contemporaneous.
Job description
Job responsibilities
Main Responsibilities
Work
in accordance with the National and Midwifery Council (NMC) Code of Conduct for
Nurses / Health Care Professionals Council / General Pharmaceutical Council and
Scope of Professional Practice
Actively network with Harrow Enhanced Practitioners to share and implement best practice and support case finding for the Harrow Frailty Service
Support the Enhanced Frailty Team in the delivery of Complex Care.
To maintain excellent working relationships with all those involved in the provision and development of services for those with long term conditions.
Attend all mandatory meetings such as Touch Point meetings and MDTs.
Managing Patients with Frailty issues
Identify, assess and signpost patients on the Frailty Team list with complex long term conditions, and nursing needs, in conjunction with GPs, district and specialist nurses and other lead clinicians.
Develop disease care management plans including self-care strategies to meet individuals complex health and nursing needs
Provide highly specialist care and advice - this could include diagnosis, management / treatment plans and referrals as appropriate.
Manage patients medicines and ensure adherence, in conjunction with GPs, consultants and specialist nurses ensuring approaches are consistent with standards, protocols and legislation
Working closely with the Health and Social Care Coordinator to ensure patients have relevant referrals and access in place to Harrow Community Services, attend and liaise with the Frailty Team MDT groups, regularly attending case conferences and providing relevant updates
Communication Skills
The post-holder will recognize the importance of effective communication within the team and will strive to:
Utilise and demonstrate sensitive communication styles to ensure patients are fully informed, and consent to treatment.
Communicate highly sensitive patient information and progress effectively with other team members and outside relevant health and social care providers, including discussion with patient about ceilings of care, urgent care plans, end of life etc.
Communicate with patients in a welcoming way, which is non-judgemental and respects patients feelings, circumstances and rights.
Ensure all documented notes are contemporaneous.
Person Specification
Qualifications
Essential
- BSc Nursing or Emergency Care Practitioner
- Management / Leadership qualifications
Desirable
- Noin- Medical Prescribing Qualification
- Specialist Older Adult Qualification
- Post Graduate diploma (DGM)
Skill / Knowledge
Essential
- Formal presentation skills for MDT.
- Evidence of cross boundary multi agency working
- Case Management and Progression
Desirable
- Catheterisation - Male and female, supra pubic
- Trial without catheter (TWOC)
- Doppler study ABPI
- Phlebotomy
- Wound care including compression bandaging
Experience
Essential
- Experience in change management
Desirable
- Involvement in research
- Evidence of management experience / training
Personal Qualities
Essential
- Due to the nature of our work, all posts are deemed to require Enhanced Disclosure clearance
Person Specification
Qualifications
Essential
- BSc Nursing or Emergency Care Practitioner
- Management / Leadership qualifications
Desirable
- Noin- Medical Prescribing Qualification
- Specialist Older Adult Qualification
- Post Graduate diploma (DGM)
Skill / Knowledge
Essential
- Formal presentation skills for MDT.
- Evidence of cross boundary multi agency working
- Case Management and Progression
Desirable
- Catheterisation - Male and female, supra pubic
- Trial without catheter (TWOC)
- Doppler study ABPI
- Phlebotomy
- Wound care including compression bandaging
Experience
Essential
- Experience in change management
Desirable
- Involvement in research
- Evidence of management experience / training
Personal Qualities
Essential
- Due to the nature of our work, all posts are deemed to require Enhanced Disclosure clearance
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).
