Job responsibilities
The Advanced Clinical
Practitioner (ACP) in Frailty plays a pivotal role in the proactive management
and care of older adults with frailty. The ACP will work collaboratively with
multidisciplinary teams to assess, diagnose, plan, and deliver high-quality,
patient-centered care to individuals living with frailty. This role focuses on
preventing the deterioration of health, improving quality of life, and managing
long-term conditions within the primary care setting.
The ACP will conduct
comprehensive assessments, including frailty screening, physical examinations,
and reviews of medical histories, to develop personalised care plans. They will
be responsible for managing complex cases, ensuring appropriate interventions,
and coordinating with healthcare professionals to support individuals across
their care journey. Additionally, the ACP will have a key role in educating
patients and their families about frailty, empowering them to make informed
decisions regarding their health and well-being.
The successful candidate will
have advanced clinical skills, experience in geriatric or frailty care, and a
strong commitment to improving outcomes for older adults in the primary care
setting. They will demonstrate the ability to work autonomously while
collaborating effectively within a multidisciplinary team.
Primary Duties and
ResponsibilitiesPatient Care:
To
work closely with the GPs, primary care and community staff in providing a service
for patients ensuring the delivery of treatment, care planning and hospital
admission prevention where appropriate.
Undertakes first line comprehensive clinical
assessment of patients, including those with complex presentations, employing
an extended scope of practice beyond own profession including advanced clinical
assessment skills, referral and interpretation of investigations and
independent prescribing.
To
provide advanced assessment and care planning, including history taking and
physical assessment of patients.
To
work closely with the consultant geriatricians, GPs and patients in identifying
and devising effective care for each patient recognising them as an
individual. The plan of care, which
should be developed in conjunction with the patient, carer/family and relevant
others, should be outcome based and ensure appropriate pathways of care and
communication via liaison and referral to other agencies as required.
To
work in conjunction with a wide range of clinical colleagues facilitating a
patient or client focused, co-ordinated case management approach across primary
and secondary care for people who are most vulnerable to and at high risk of
repeat admissions to hospital
To
participate in efforts to shape multi-disciplinary pathways designed to support
patient choice, improve quality of life, promote self-management and assure
early intervention through the proactive provision of care in or as close to
the patients own home as possible
Requests, reviews and interprets diagnostic
investigations within the context of other available information utilising a
systematic process of clinical reasoning to formulate a differential diagnosis.
Involves patients, families and carers in the
identification of patient-centred concerns and priorities about health and
well-being and negotiates approaches available to prevent deterioration or promote
comfort and well-being.
Demonstrates empathy and compassion when
communicating sensitive information and advice to patients, carers and
relatives.
Evaluates the effectiveness of therapeutic
interventions and modifies the management plan accordingly.
Adopts an integrated care approach to meeting an
individual patients needs across services through collaboration with care
teams who refer patients to the service and those who provide on-going care
after discharge
Assesses capacity, gains valid informed consent
and works within a legal framework with patients who lack capacity to consent
to treatment.
Provides guidance to the clinical team with
regard to therapeutic interventions, advance care planning and best interest
decision-making for patients who lack mental capacity
Recognises deteriorating patients, implements
early interventions as needed and escalates care where appropriate.
Empowers patients to manage their long-term
conditions as independently as possible.
Applies expert knowledge in palliative care to
symptom control, recognition of dying and advance care planning.
Refers to other practitioners and agencies when
necessary.
Communication and Working Relationships:
Ensure
close liaison with GPs, clinicians, consultant geriatrician, and General
Manager in communicating clinical issues
Facilitates
the communication of highly complex information regarding specialist issues on
a range of service developments with the Practice and other health and social
care professionals. This communication
is directed to professional colleagues, across all areas of the health economy
and primary care networks in the CCG area.
Advanced
communication skills are necessary to communicate with patients to gain consent
for treatment within a care pathway. Highly
sensitive and confidential information is regularly required to be communicated
to patients after clinical and medical results are collated, formulating
specific management plans which can be upsetting in nature.
Responsible
for developing and maintaining effective communication channels with patient,
carers and other health and social care professionals.
Promote
empathy, enable sharing of complex multi-professional viewpoints and sensitive
handling of confidential information
Analytical and Judgement:
The
ACP will work across the caseload using their clinical skills to identify the
needs of patients and the correct services to liaise with.
Advise
on the promotion of health and prevention of illness and provide information to
individual and groups to prevent ill-health.
To
provide specialist assessment of patients, using analytical and judgement
skills. To provide appropriate patient
centred treatment using evidence based practice wherever possible.
Analyses
and interprets highly complex information gained during clinical examination
and history taking to diagnose an individuals problems or illness and to
decide on an appropriate course of action or treatment.
Analyses
and interprets results from tests and investigations to inform diagnosis and
treatment
Able
to access and assimilate previous patient records where available
Identifies
evidence based interventions to meet an individuals complex health needs
within the context of the overall management plan
Supports the development of a learning
organisation by identifying, challenging and reporting poor performance and
alerting managers to resource issues which may affect patient safety.
Training and
Development:Continuous
Professional Education:
Engage in ongoing professional development through formal courses, workshops,
conferences, and e-learning to maintain and enhance clinical expertise in
frailty care.
Clinical
Supervision and Mentorship:
Provide clinical supervision, mentorship, and guidance to junior healthcare
professionals, including nurses, trainees, and other allied health staff,
fostering a culture of learning within the team.
Knowledge
Sharing: Lead and
participate in training sessions, case discussions, and in-service education
for the primary care team to raise awareness of frailty issues, management
strategies, and best practice guidelines
Role
Development:
Actively contribute to the development and expansion of the ACP role within the
older persons team by identifying new learning needs and areas for service
improvement.
Research
and Evidence-Based Practice:
Stay up-to-date with the latest research, evidence, and best practices in
frailty care, and incorporate these findings into both personal practice and
team training initiatives.
Collaboration
with Academic Institutions:
Build relationships with universities or training providers to facilitate
learning opportunities for students or apprentices in frailty care.
Audit
and Quality Improvement:
Participate in audits and quality improvement initiatives to assess the
effectiveness of frailty management approaches and use the findings to inform
training and development activities.
Personal Reflection
and Development Plans:
Regularly review personal performance and clinical outcomes, setting
development goals and seeking feedback from peers and supervisors to ensure
ongoing professional growth.
Safeguarding:
Whitstable Medical Practice is committed to safeguarding and promoting
the welfare of children, young people and vulnerable adults; and expects all
staff and post holders to share this commitment by understanding their role in
effective safeguarding.
