Job summary
This is an exciting opportunity to join our evolving Integrated Frailty Team across 3 Harbours and Bosvena Primary Care Network. You will be working alongside our care coordinators, clinicians, community nursing teams as well as volunteer and community sector providers to support those patients who are considered frail, long-time or acutely housebound, as well as supporting nursing and residential homes within our Integrated Neighbourhood.
With knowledge and skills in frailty, physical assessment and clinical reasoning, diagnostic reasoning , actioning the necessary long-term condition and medication reviews, you will use these skills to assist in the recognition and support of early symptoms of frailty, disease exacerbation, acute illness and injuries.
Main duties of the job
- You will:
- Be able to respond to urgent referrals for patients, carers and the multi-disciplinary team.
- Case manage and coordinate with adult social care for packages of care
- Work within the framework of an MDT
- Be responsible for assessing, diagnosing, planning, organising and reviewing complex packages of care, including case conferences.
- Provide holistic evidence based/best practice care to patients in accordance with National Organisational approved policies/procedures and individual care plans.
- Ensure privacy, dignity and human rights are respected for all patients and carers.
- Undertake comprehensive risk assessments of all situations associated with the care of patients to ensure professionals' and the carers' safety.
- Work alongside Occupational Health colleagues to assist with assessments which might include the provision of equipment ensuring it is used safely and within the manufacturer's guidance.
- Report and record all incidents according to health and safety policy, guidance and legislation.
- Document and maintain confidential, accurate, and legible records using an agreed reporting / clinical system.
- Be expected to oversee the standard of patients' records by audit or peer review and have regular open discussion with team members.
- Be required to comply with all infection control policies and guidance, attend relevant updates and report issues of concern to their immediate line manager
- Consider safeguarding in line with organisational policy
About us
Our primary care network spans coastal, town and rural Cornwall including Bodmin, Fowey, Lostwithiel and Par. We are developing our integrated neighbourhood team, working with social care, community partners, secondary care and voluntary sector providers, to deliver high quality, patient centred health care across our geography.
Job description
Job responsibilities
Management & Leadership:
- To have an awareness of key MDT targets and priorities in terms of the operational/strategic plan for the system and related initiatives; to actively support the organisation in delivering high quality care and maintaining Care Quality Commission Compliance (CQC).
- To comply with relevant national guidelines, including NICE Guidance and National Standards Framework and within a scope of your own clinical standards.
- To contribute to the identification and development of relevant clinical protocols and strategies to enhance both the continuity and standard of specialist care whilst ensuring equity of access to the service, ensuring that all care is given in accordance with agreed protocols.
- To work with the MDT to develop, implement and evaluate integrated care pathways and systems of MDT documentation.
- Participate in policy development through professional forums and implement practice ensuring the clinical practice reflects national and local drivers
Communication:
- Maintain and foster good relationships with all colleagues concerned with the provision or development of healthcare services.
- Forge effective links within Primary, secondary and community services to ensure effective communication through appropriate forums.
- Timely recording patient activities for IT data collection, dealing with e-mail queries, stock and equipment ordering.
- Preserve confidentiality and compliance to GDPR, Data Protection Act, Access to Health Records and Consent for Treatment.
- Demonstrate good communication skills to facilitate effective communication with patients and their carers, including sensitive and accurate information about their condition.
- Provide and receive complex, sensitive and confidential information and overcome potential barriers to communication, such as language, disability.
- Inform other professionals about changes in patients' condition.
- Act as a patient advocate as required ensuring individual needs, preferences and choices are delivered by the Service.
Education & Training:
- Assume responsibility for own professional development and personal knowledge.
- Monitor own performance against agreed objectives through the process of IPR and personal development plans, Professional regulations and maintain professional expertise by arranging and attending meetings, study days and in service training for the team members.
- Facilitate and develop team members.
- Participate in Reflective Practice, Practice Supervision and Appraisals as per organisational) policies.
- Support student development and placement
- Plan and participate in the supervision, teaching and provision of community experience for all nurse learners and other personnel as appropriate.
- Develop the learning environment to promote lifelong learning and staff development. Identify areas of practice/role development and enable and support staff to initiate change.
- Work towards becoming an Independent Prescriber
Care home support responsibilities, as required:
(may include covering team absence or annual leave)
- Weekly check-in meetings with homes - which should include: facilitating and managing the delivery of the review (either remotely or in person, wherever appropriate), facilitated by an MDT where practically possible.
- Review patients identified by the care home as a clinical priority for assessment, review any new residents.
- Support the provision of care for those patients identified as a clinical priority; include appropriate and consistent medical oversight with liaison / input from a GP and/or geriatrician (with the frequency and form of that input determined by clinical judgement).
- Support homes with end of life care planning as required
- Support homes as appropriate with care planning establishing a process to:
- Support development of personalised and individually agreed treatment escalation plans for care home residents with care home teams, including end of life care plans.
- The role should work towards implementing the Comprehensive Geriatric Assessment.
- Facilitate the timely appropriate use of medication reviews, working with the Pharmacy Technician, including:
- medication supply , including end of life medication.
- Arranging the delivering structured medication reviews - via video or telephone consultation where appropriate - to care home or housebound residents.
- Supporting reviews of new residents or those recently discharged from hospital to patients home or care home beds
- To support older patients and patients with moderate and severe frailty in their own homes by:
- Identification of patients using an agreed case finding tool (Electronic Frailty Index [eFI] or Rookwood score) who require completion of a Comprehensive Geriatric Assessment (CGA). Patients should be considered for MDT/caseload management following assessment.
- Participating in annual reviews for housebound patients with long-term chronic conditions.
- Signposting to other services/voluntary sector as appropriate and to consider social prescribing, (for example, in support of alleviating loneliness brought on by social isolation)
- Organisation and attendance at Primary Care Network (Bosvena) Multi-Disciplinary Team (MDT) meetings
Job description
Job responsibilities
Management & Leadership:
- To have an awareness of key MDT targets and priorities in terms of the operational/strategic plan for the system and related initiatives; to actively support the organisation in delivering high quality care and maintaining Care Quality Commission Compliance (CQC).
- To comply with relevant national guidelines, including NICE Guidance and National Standards Framework and within a scope of your own clinical standards.
- To contribute to the identification and development of relevant clinical protocols and strategies to enhance both the continuity and standard of specialist care whilst ensuring equity of access to the service, ensuring that all care is given in accordance with agreed protocols.
- To work with the MDT to develop, implement and evaluate integrated care pathways and systems of MDT documentation.
- Participate in policy development through professional forums and implement practice ensuring the clinical practice reflects national and local drivers
Communication:
- Maintain and foster good relationships with all colleagues concerned with the provision or development of healthcare services.
- Forge effective links within Primary, secondary and community services to ensure effective communication through appropriate forums.
- Timely recording patient activities for IT data collection, dealing with e-mail queries, stock and equipment ordering.
- Preserve confidentiality and compliance to GDPR, Data Protection Act, Access to Health Records and Consent for Treatment.
- Demonstrate good communication skills to facilitate effective communication with patients and their carers, including sensitive and accurate information about their condition.
- Provide and receive complex, sensitive and confidential information and overcome potential barriers to communication, such as language, disability.
- Inform other professionals about changes in patients' condition.
- Act as a patient advocate as required ensuring individual needs, preferences and choices are delivered by the Service.
Education & Training:
- Assume responsibility for own professional development and personal knowledge.
- Monitor own performance against agreed objectives through the process of IPR and personal development plans, Professional regulations and maintain professional expertise by arranging and attending meetings, study days and in service training for the team members.
- Facilitate and develop team members.
- Participate in Reflective Practice, Practice Supervision and Appraisals as per organisational) policies.
- Support student development and placement
- Plan and participate in the supervision, teaching and provision of community experience for all nurse learners and other personnel as appropriate.
- Develop the learning environment to promote lifelong learning and staff development. Identify areas of practice/role development and enable and support staff to initiate change.
- Work towards becoming an Independent Prescriber
Care home support responsibilities, as required:
(may include covering team absence or annual leave)
- Weekly check-in meetings with homes - which should include: facilitating and managing the delivery of the review (either remotely or in person, wherever appropriate), facilitated by an MDT where practically possible.
- Review patients identified by the care home as a clinical priority for assessment, review any new residents.
- Support the provision of care for those patients identified as a clinical priority; include appropriate and consistent medical oversight with liaison / input from a GP and/or geriatrician (with the frequency and form of that input determined by clinical judgement).
- Support homes with end of life care planning as required
- Support homes as appropriate with care planning establishing a process to:
- Support development of personalised and individually agreed treatment escalation plans for care home residents with care home teams, including end of life care plans.
- The role should work towards implementing the Comprehensive Geriatric Assessment.
- Facilitate the timely appropriate use of medication reviews, working with the Pharmacy Technician, including:
- medication supply , including end of life medication.
- Arranging the delivering structured medication reviews - via video or telephone consultation where appropriate - to care home or housebound residents.
- Supporting reviews of new residents or those recently discharged from hospital to patients home or care home beds
- To support older patients and patients with moderate and severe frailty in their own homes by:
- Identification of patients using an agreed case finding tool (Electronic Frailty Index [eFI] or Rookwood score) who require completion of a Comprehensive Geriatric Assessment (CGA). Patients should be considered for MDT/caseload management following assessment.
- Participating in annual reviews for housebound patients with long-term chronic conditions.
- Signposting to other services/voluntary sector as appropriate and to consider social prescribing, (for example, in support of alleviating loneliness brought on by social isolation)
- Organisation and attendance at Primary Care Network (Bosvena) Multi-Disciplinary Team (MDT) meetings
Person Specification
Experience
Essential
- - Understanding of the particular requirements of elderly patients within an acute and community setting and the knowledge and skills to assess patients with commonly recognised admission criteria E.g. Falls, Urinary Tract and Lower Respiratory tract infections, Delirium and Dementia, heart failure and COPD/asthma exacerbations.
- - Ability to prioritise individuals for assessment and management according to their health status and needs, referring for specialist assessment, diagnostic tests and programs of support as appropriate.
- Develop person led single geriatric care plans in partnership with patients and their relatives.
- - Initiate and ensure Advanced Care Planning is undertaken at appropriate stage of disease process/frailty trajectory, ensuring patients goals are met when requiring palliative care or end of life care in line with Local Organisational End of Life Strategy and NICE Clinical Guidelines.
Desirable
- - An autonomous practitioner who will provide expert clinical case management for Care Home and frail patients with acute/intensive medical needs and at risk of further deterioration in health that may result in avoidable hospital admission or unnecessary length of hospital stay.
- - Responsible for facilitating efficient, effective coordinated assessments and treatment for frail adults under supervision of Clinical Frailty lead
- Gathering and interpreting information from various IT systems and sources, performing tests and analysing results, recording collated information using a Single Assessment Pathway Support.
- - Facilitate person led early discharge plans working in collaboration with hospital MDT and discharge teams ensuring the patient's needs are met and likelihood of unnecessary readmission is reduced.
- - Actively seeking out patients who will benefit from clinical case management technique in order to avoid unplanned hospital admission and reduce the length of hospital stays.
- - Ability to prioritise individuals for assessment and management according to their health status and needs, referring for specialist assessment, diagnostic tests and programs of support as appropriate.
- - Commitment to provide clinical support to patients, their families/carers and professionals involved across the Frailty pathway.
- - 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.
- - Integrating the three key aspects of clinical practice, education and research whilst collaborating closely with other members of the multi-disciplinary team to develop and monitor standards of care.
- - 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.
- - Support the delivery of frailty audit and service improvement initiatives.
- - Using referral criteria, clinical knowledge and experience identify and assess patients who are suitable for a full CGA assessment.
- - Completion of CGA including collateral social and past medical history from patients, family, care providers, community and primary care services.
- - Document full CGA and formulate an appropriate plan.
- - Refer to MDT to identify, review and support patients with complex disease management who are either at risk of admission, have repeated active hospital admissions to develop their knowledge and understanding about their health and well-being to enable self- management within individual abilities.
- - Enhanced Care Planning for end of life patients and completion of Treatment Escalation Plan (TEP).
Other requirements
Essential
- Driving licence and vehicle are required for this role.
Person Specification
Experience
Essential
- - Understanding of the particular requirements of elderly patients within an acute and community setting and the knowledge and skills to assess patients with commonly recognised admission criteria E.g. Falls, Urinary Tract and Lower Respiratory tract infections, Delirium and Dementia, heart failure and COPD/asthma exacerbations.
- - Ability to prioritise individuals for assessment and management according to their health status and needs, referring for specialist assessment, diagnostic tests and programs of support as appropriate.
- Develop person led single geriatric care plans in partnership with patients and their relatives.
- - Initiate and ensure Advanced Care Planning is undertaken at appropriate stage of disease process/frailty trajectory, ensuring patients goals are met when requiring palliative care or end of life care in line with Local Organisational End of Life Strategy and NICE Clinical Guidelines.
Desirable
- - An autonomous practitioner who will provide expert clinical case management for Care Home and frail patients with acute/intensive medical needs and at risk of further deterioration in health that may result in avoidable hospital admission or unnecessary length of hospital stay.
- - Responsible for facilitating efficient, effective coordinated assessments and treatment for frail adults under supervision of Clinical Frailty lead
- Gathering and interpreting information from various IT systems and sources, performing tests and analysing results, recording collated information using a Single Assessment Pathway Support.
- - Facilitate person led early discharge plans working in collaboration with hospital MDT and discharge teams ensuring the patient's needs are met and likelihood of unnecessary readmission is reduced.
- - Actively seeking out patients who will benefit from clinical case management technique in order to avoid unplanned hospital admission and reduce the length of hospital stays.
- - Ability to prioritise individuals for assessment and management according to their health status and needs, referring for specialist assessment, diagnostic tests and programs of support as appropriate.
- - Commitment to provide clinical support to patients, their families/carers and professionals involved across the Frailty pathway.
- - 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.
- - Integrating the three key aspects of clinical practice, education and research whilst collaborating closely with other members of the multi-disciplinary team to develop and monitor standards of care.
- - 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.
- - Support the delivery of frailty audit and service improvement initiatives.
- - Using referral criteria, clinical knowledge and experience identify and assess patients who are suitable for a full CGA assessment.
- - Completion of CGA including collateral social and past medical history from patients, family, care providers, community and primary care services.
- - Document full CGA and formulate an appropriate plan.
- - Refer to MDT to identify, review and support patients with complex disease management who are either at risk of admission, have repeated active hospital admissions to develop their knowledge and understanding about their health and well-being to enable self- management within individual abilities.
- - Enhanced Care Planning for end of life patients and completion of Treatment Escalation Plan (TEP).
Other requirements
Essential
- Driving licence and vehicle are required for this role.
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).
