Frailty Practitioner (18 hours per week)

Job responsibilities

Please see the attached document for more details.

Key Responsibilities

Moderate and Severe Frailty

Case Identification:

Use 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 the Care Coordinator 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

- Support the Care Coordinator 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 Administrator to ensure all post MDT meetings are carried out in a timely and effective manner

General

Leadership:

- Provide leadership and support to the Health and Wellbeing Coach and Care Coordinator(s)

- 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 team care coordinators, frailty team administrators, 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.

Knowledge, Skills and Experience

- Advanced clinical assessment and diagnostic skills, particularly in geriatric and frailty syndromes.

- Expertise in frailty identification and screening tools (e.g. Clinical Frailty Scale, eFI).

- Sound understanding of long-term condition management, rehabilitation and end-of-life care.

- Proven ability to work effectively within MDTs and across organisational boundaries.

- Understanding of personalised care, wider determinants of health and equality, diversity and inclusion

Excellent communication and interpersonal skills to:

- engage with and enable people, families and carers using health coaching approaches

- enable efficient multi-agency working with practitioners across the system adopting a team of teams approach, especially with the local Integrated Neighbourhood Team

Competence in using digital health records and remote monitoring tools.

Clinical Knowledge and Skills

Essential

• Understanding of the importance of evidence-based practice
• Ability to promote best practice regarding nursing matters
• Clinical knowledge and skills relevant to the care of people living with frailty and/ or dementia.
• Ability to work within own scope of practice and understanding when to refer to GPs
• Good clinical system IT knowledge and the ability to record accurate clinical notes
• Broad knowledge of clinical governance
• Understanding of safeguarding adults and children
• Knowledge of public health issues in the local area and issues in the wider health arena
• Understanding of health promotion strategies
• Excellent interpersonal, influencing, negotiation and organisation skills with the ability to constructively challenge the view and practices of managers and clinicians

Desirable

• Understanding and knowledge of healthcare provision in GP surgeries
• Detailed knowledge of national standards that inform general practice (NSF NICE guidelines)

Personal Qualities

Essential

• Effective time management (planning and organising)
• Demonstrate personal accountability, emotional resilience and work well under pressure
• Ability to follow legal, ethical and professional policies/ procedures and codes of conduct
• Ability to work as a team member and autonomously
• Good interpersonal and organisational skills
• Sensitive and empathetic in distressing situations
• Knowledge of and ability to work to key policies and procedures

Desirable

• Knowledge of IT systems including the ability to use word processing skills, emails and the internet
• Ability to identify risk and assess/manage risk when working with individuals

Experience

Essential

• - Understanding of general practice and the wider NHS
• - Experience of practice within the four pillars
• - Experience of infection prevention and control measures
• - Experience of quality initiatives, i.e., benchmarking

Desirable

• - Experience of working as a practice nurse or community nurse
• - Experience of prescribing and undertaking medication review
• - An appreciation of the new NHS landscape including the relationship between individual organisations, PCNs and the commissioners

Other requirements/wider responsibilities

Essential

• Enhanced Disclosure Barring Service (DBS) check
• Occupational Health clearance
• Meet the requirements and produce evidence for nurse revalidation
• Evidence of continuing professional development (CPD) commensurate with the role
• Access to own transport and ability to travel across the locality on a regular basis

Desirable

• Flexibility to work outside core office hours

Qualifications

Essential

• - Registered Nurse with Nursing and Midwifery Council (NMC)
• - Has evidence of working at an enhanced level
• - Meets NMC revalidation requirements in accordance with the NMC Revalidation booklet
• - Confirmation of registration with the NMC

Desirable

• - Masters degree required for qualification post December 2020 refer to RCN Credentialing for Advanced Level of Nursing Practice (ALNP) or, a degree for Advanced Practice Qualification up to December 2020
• - Qualified Independent Nurse Prescriber on the NMC register

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).