PCN Frailty Practitioner

Job responsibilities

Duties specific to role

With a focus on prevention, the role is pivotal in the delivery of the NHSE Proactive Care Framework at PCN level for people living with moderate or severe frailty, working collaboratively with multi-agency multi-disciplinary teams (MDTs) and system partners to enhance independence and quality of life and in turn reduce the risk of unplanned hospital admissions.

Case Identification:

Use eFI/ Personal Proactive Whiteboard to identify list of potential patients living with moderate or severe frailty, supported by sub-cohort analysis, with the aim of identifying the highest risk patients

Holistic Assessment:

Provide support to administrators to ensure the self-assessment questionnaire process is carried out effectively and to a high-quality standard

Triage potential patients to determine which will receive a comprehensive geriatric assessment (CGA)

Determine what action to take with those patients who do not receive a CGA and ensure those actions are undertaken

Undertake CGAs as determined for relevant patients, inputting information into the digital template and ensuring they are given a Rockwood Score. Draw in clinical support as required from the PCN Frailty Teams GP with an interest in Frailty for those patients with a higher acuity of need.

Personalised Care and Support Planning:

Ensure a Personalised Care and Support Plan (PCSP) is produced and agreed with the relevant patient and any carer/family, along with a ReSPECT plan

Coordinated and Multi Professional Working:

Ensure close multi-professional and multi-agency working, especially with other members of the local Integrated Neighbourhood Team(s), to facilitate the delivery of each patients PCSP

Continuity of Care including reviews

Work with rest of the frailty team to ensure regular review of patients take place as planned and agreed according to the individual needs of the person and /or following trigger events such as hospital admission.

Dementia Co-diagnosis

Determine the frequency of MDT meetings, depending on demand; keep under regular review

Support the Frailty Team Care Navigator to ensure all post MDT meetings are carried out in a timely and effective manner

Other Clinical

Within competencies and training:

• Undertake comprehensive assessment, diagnosis, and treatment of patients with undifferentiated and undiagnosed problems, both acute and chronic.
• Prescribe and review medication in accordance with national and local prescribing guidelines.
• Order and interpret investigations to inform clinical decision-making.
• Identify and manage long-term conditions, health promotion, and disease prevention strategies.
• Recognise and respond to medical emergencies and deteriorating patients.

General

Leadership:

• Provide leadership and support to the Frailty Care Navigator
• Clinical Leadership: Provide clinical assessment, diagnosis, and case management of people living with frailty in the community using agreed standardised tools and templates. Responsible for Frailty Care Navigator, managing caseloads and ensuring the appropriate allocation of personnel and tasks to team members

Partnership Working: Build and maintain effective working relationships with GPs, acute and community hospitals, Adult Social Care, voluntary sector organisations, and other community services to deliver integrated care

Care Coordination: Ensure seamless transitions of care and continuity through proactive case management and liaison with all relevant stakeholders

MDT Coordination: Lead and participate in MDT meetings, ensuring collaborative care planning and shared decision-making across system partners

Education and Training: Support the development of frailty awareness and skills for other practitioners, carers, and patients

Service Development: Contribute to the design, implementation, and evaluation of frailty pathways and services

Risk Management: Identify and manage clinical risks, including falls, polypharmacy, and cognitive decline

Patient Advocacy: Promote shared decision-making and ensure care aligns with patients values, goals and what matters to them

Data and Audit: Collect and analyse data to:

• support risk stratification and segmentation of the patient cohort,
• enable use of the Personalised Proactive Whiteboard for care coordination,
• monitor outcomes and measure impact, support quality improvement and inform commissioning conversations.

Professional

• Maintain professional registration with the appropriate regulatory body (eg NMC/HCPC).
• Engage in clinical supervision and maintain an up-to-date professional portfolio.
• Participate in continuing professional development and annual appraisal.

Non-medical prescribing/independent prescribing (if applicable)

As a qualified non-medical prescriber (NMP)/independent prescriber (IP), prescribing will be undertaken within the scope of practice of the prescriber and in accordance with their professional code of conduct as set out by their own regulatory bodies and organisational NMP policy.

Working conditions

The job is primarily Gloucester-based, but you will be required to travel independently between services in Gloucestershire and, occasionally, in other areas of the UK.

Frequent, prolonged VDU use

Time-pressured environment

High levels of accuracy and attention to detail essential at all times

Exposure to distressing situations and written material

Contact with body fluids, i.e. wound exudates; urine etc. while in clinical practice.

Uniform/scrubs to be worn as agreed with line manager

The job description for all G DOC workers also forms part of your job description.

Other

Essential

• Disclosure Barring Service (DBS) enhanced check satisfactory
• Evidence of continuing professional development
• An ability to drive, current UK driving licence. and daily access to a vehicle.

Experience

Essential

• Minimum 2 years post-registration experience
• Proven experience in autonomous clinical decision-making
• Experience in managing long-term conditions

Desirable

• Experience of working with older people
• Experience of General Practice
• Experience in managing end of life care
• Expertise in frailty identification and screening tools
• Experience of working effectively within MDTs or equivalent groups
• Experience of mentoring and supervising other clinicians
• Experience using remote monitoring tools

Qualifications

Essential

• Registered with relevant professional body (eg NMC, HCPC or equivalent)

Desirable

• MSc Advanced Clinical Practice or NMC/HCPC-recognised equivalent

Qualifications

Essential

• Registered with relevant professional body (eg NMC, HCPC or equivalent)

Desirable

• MSc Advanced Clinical Practice or NMC/HCPC-recognised equivalent

Skills

Essential

• Excellent communication and consultation skills
• Able to manage, monitor and review long term conditions
• Sound understanding of clinical governance and safeguarding
• Advanced assessment, diagnostic reasoning, and treatment planning skills
• Strong IT skills
• Willing to become competent in use of SystmOne if not already
• Competent in the use of Office software
• Ability to follow policy and procedure
• Able to identify and resolve risk management issues according to policy or protocol
• Effective time management
• Ability to work as a team member and autonomously
• Good interpersonal skills

Desirable

• Knowledge of QOF, enhanced services, and primary care targets
• Health coaching
• Competent in use of SystmOne
• Audit and research skills
• Teaching and mentoring skills

Personal qualities

Essential

• Clear, polite telephone manner
• Polite and confident
• Flexible and cooperative
• Motivated
• High levels of integrity and loyalty
• Sensitive and empathetic in distressing situations
• Ability to work under pressure

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).