Frailty Practitioners – Ashford Hub

Overview

Contract Type: Permanent

Salary: inclusive of 5% High Cost Area allowance per annum pro rata

Partner Org: Central Surrey Health

Job summary

The post holder will deliver expert clinical care, support and advice in accordance with national and local policy and guidance and in accordance with the Nursing and Midwifery Council / Health Care Professional Council (HCPC) code of professional practice.

Work as an integral part of the Integrated multi-Professional team including GPs, community nurses, social care, District & Boroughs, mental health colleagues, Therapy colleagues and the voluntary sector in the North-West Surrey Neighbourhood Boroughs.

Lead and facilitate a patient focused, coordinated case management approach, supporting people who are most vulnerable and at high risk of unnecessary admission to hospital, supporting persons discharged from acute hospitals onto the VW, promoting pro-active care and ensuring persons have a personalised care plan and or advanced care plan to support their needs and to maintain their independence.

Please note we do NOT offer UKVI sponsorship, all applicants require right to work in the UK.

Main duties of the job

• Identifies patients at high risk of unnecessary admission to hospital / decline in health and or wellbeing and uses proactive management approach to promote wellness, early recognition of disease exacerbation, and appropriate intervention to improve patient outcomes and reduce the likelihood of unnecessary admissions to hospital.
• Documents holistic advanced assessments, taking into account physical and psychological social needs and those of their carers to inform and agree individualised care plans with the patient.
• Interprets complex information and formulates solutions to recommend on the best course of action/treatment for the patients, persons, e.g. medication reviews Psycho-social needs.
• Act as an independent decision maker with regard to referrals to other agencies and for the admission /discharge for that episode of care.
• At all times, ensures that patients and their carers experience a high quality and patient centred service, ensuring that care is accessible, effective and delivered at a time and place according to clinical need
• Trained and competent to undertake physical examination of the circulatory, respiratory and other systems including listening to heart and lungs and regularly undertaking the following: venepuncture, male and female catheterisation, injections and basic wound care.
• Interprets findings from diagnostic tests/examination and uses this to make clinical decisions about care and treatment.
• As a non-medical prescriber (NMP), work within the scope of national and local protocols. This will include attending regular updates in line with CPD and revalidation requirements, the initiation of medication regimes, agreeing changes, monitoring the effects of medications, advising patients on the safe storage and disposal of drugs.
• Works in partnership with NWS Alliance Colleagues, to include specialists, Social Care & Borough colleagues, MDTs and GPs in facilitating safe discharge home from hospital or following an A&E attendance.
• Responsible for preparing the patient and their family for changes in condition and support choice about end-of-life care, ensuring that patients needs, and those of their families are met, this will include active management of complex pain and symptom control.
• Provides information about the disease process to assist patients and their families in understanding and self-managing their long term condition.
• Responsible for prescribing the correct use of aids and equipment relevant to a frailty practitioner role and in line with patient need.
• Responsible for ensuring effective communication with all relevant personnel pertaining to patient care and any change in treatment/management plans, part of this will include the effective use of electronic notes system, including assessment tools.
• Responsible for establishing, communicating and maintaining effective professional relationships with INT colleagues, which does include Primary Health Care, health/social care/voluntary service networks to provide a planned, co-ordinated, seamless service for patients clients within the Neighbourhood footprint.
• Influences efforts across health and social care to shape integrated working designed to support patient choice, improve quality of life, promote self-management and assure early intervention through the proactive provision of care in the least intensive setting possible.
• Considers and uses new ways of working, efficiencies, evidence based research and best practice at all times to support change management, this included supporting Total Triage, Virtual Wards and Transfer of Care Hubs (pathways in and out of Hospital).
• Recognises own limitations in the provision of clinical care and urgency of patients needs, referring to other health care professionals such as specialist nurses without direct supervision.
• Maintains accurate clinical records and activity data and uses information from a wide range of sources, some of which may be conflicting, to inform clinical decision making – with due regard to confidentiality and data protection at all times.
• Reports any identified risk ensuring steps are taken to mitigate any identified risks in daily work and making rapid autonomous decisions to provide appropriate management of the service.
• Reports clinical incidents and near misses and sets action plans to ensure learning is shared and to mitigate against repeat incidents / near misses.
• Maintains own personal knowledge and skills through continuous professional development, clinical supervision, peer review, educational updates and own clinical practice in line with current research and evidence based practice.
• Assess and participates in clinical supervision and peer review in line with revalidation regarding professional organisations.
• Responsible for teaching and supervising others including post registration students, non-registrants working within the integrated neighbourhood team. Ensures own annual appraisal is undertaken, setting objectives in line with the organisation.
• Responsible for the regular on-going audit of the case management approach and for participating in audit as identified in audit plans.
• Actively participates in meetings to continually develop the Integrated Neighbourhood teams, through disseminating information, consulting with colleagues to positively effect change.

Please refer to the attached Job Description and Personal Specification for more information including essential and desirable criteria.

IMPORTANT: Before applying for this role, please make sure you have the right to work in the country where the role is based. Unless it clearly stipulates within in the job advert above that the hiring company is looking to or able to sponsor applicants it is deemed that the hiring employer will only consider applications from those able to comply with and work in the country where the role is based.