Job summary
An
exciting opportunity has arisen for a Frailty Practitioner to join our newly
formed frailty team at Livewell Southwest. This post is suitable for a
Physiotherapist, Occupational Therapist or Registered Nurse delivering care to
adults experiencing decompensation in physical, psychological, or social
well-being. The ability to assess and treat the person as a whole, considering
all aspects of their life which may be impacting their condition, is the key to
successful management of frailty.
The
successful applicant will work collaboratively with Livewells community
integrated teams and the Primary Care Networks across the city as a core member
of the Ageing Well Multidisciplinary Team (MDT), with the ability to facilitate
optimal outcomes and reduce avoidable hospital admissions through promoting
independence and improving quality of life.
There
will be opportunities for upskilling and skill sharing for the successful
applicant, although we also recognise the desire for individuals to maintain
their own professional registration and maintain their competencies.
"please note that this role may not be eligible for sponsorship under the Skilled Worker route, please refer to the Direct Gov website for more information with regards to eligibility"
Main duties of the job
Attendance
of weekly multi-disciplinary team meetings including GPs and Livewell community
services with shared support across the integrated care system
Adopting
a holistic approach to assessments to detect declines in functional ability and
deliver interventions aiming to delay frailty progression and optimise quality
of life
Completion
of comprehensive geriatric assessments (CGA) including:
Identification
of patient goals and devising realistic plans to achieve them
Long
term conditions review and functional assessments focussing on optimising
symptoms through medical and therapeutic intervention
Provision
of suitable equipment and adaptations to support independence within their own
home
Identify
issues with polypharmacy and action necessary medication reviews/deprescribing
Advance
care planning and discussions to support writing of TEP forms
Assessment
of activities of daily living including social and cognitive vulnerabilities
and consider where cognitive assessments may be required
Third
sector signposting for support as and when required
Maximising
function and independent living with education/advice, equipment provision
and rehabilitation plans guided by personalised goal setting
Proactive
management aiming to prevent avoidable hospital admissions and reduce duplication
across community service waiting lists through timely and preventative
assessment and care-planning
About us
Livewell Southwest is an independent, award-winning social enterprise providing integrated health & social care services for people across Plymouth, South Hams & West Devon, as well as some specialist services for people living in parts of Devon & Cornwall. With teams in community hospitals, GP practices, sports centres, health & wellbeing hubs.
As an organisation with a strong social conscience, we always value being kind, respectful, inclusive, ambitious, responsible and collaborative. Transforming services to make them sustainable, ensuring that we value, support & empower each other.
We are committed to involving the people we care for, families & carers in everything that we do, working towards co-production where we can. Helping us to deliver the right care for people, in the right place & at the right time. By putting people at the centre of what we do, we ensure to support people to lead, healthy independent lives & be the very best at helping people to live well.
Valuing our employees making an investment in their development a priority. We offer:
Protected CPD time for registered staff
Various development pathways and ongoing regular training packages for all staff
Leadership & mentoring programmes
Access & funding for training including Care Certificate, Assistant Practitioners Course & Scholarship Into Nurse Training
A Robust Preceptorship
A bespoke induction programme
Existing members of the NHS Pension Scheme can continue their membership when they join the organisation.
Job description
Job responsibilities
1.
The post holder will be the lead specialist in frailty for community integrated
teams. This includes physical and functional assessment, clinical reasoning,
diagnostic reasoning and the ability to identify issues with polypharmacy in
frailty to action the necessary medication review. Using these skills will
assist in the recognition of early symptoms of frailty, disease exacerbation,
acute illness and injuries.
2.
An autonomous practitioner who will provide expert clinical case management for
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. Be responsible for facilitating efficient,
effective co-ordinated assessments and treatment for frail older adults.
3.
Undertakes specialist frailty assessment, plans and implements care in a
variety of settings, provides highly specialist advice to patients/clients,
carers, relatives and other professionals; maintains associated records.
4.
Develops and delivers specialist frailty education programmes to service users,
families and professionals.
5.
Key member of the Ageing Well Multidisciplinary Team (MDT), and lead
practitioner to support Livewell community integrated teams in completion of
comprehensive geriatric assessment, working in conjunction with primary care
network colleagues.
6.
Using referral criteria and an agreed case finding tool (Electronic Frailty
Index [eFI] or Rockwood score), identify and assess patients who are suitable
for a full CGA assessment.
7.
Completion of CGA including collateral social and past medical history from
patients, family, care providers, community and primary care services. Liaise
where appropriate with health and social care and other external agencies.
8.
Document full CGA and formulate an appropriate person-centred plan. Collaborate
with the 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.
9.
To be responsible for the advanced assessment, treatment and management of
patients. Negotiate, agree expectation and set appropriate, realistic and
individual goals in partnership with the patient, carer and colleagues
10.
Take a lead role by offering professional support within the MDT when dealing
with complex/urgent situations which can be emotionally challenging e.g.
terminal illness.
11.
[Where indicated] Initiate and ensure Advanced Care Planning and completion of
Treatment Escalation Plan (TEP) 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 Authority and
Organisational End of Life Strategy and NICE Clinical Guidelines.
12.
Make independent referrals for diagnostic tests and/or opinions and care which
requires open and informed discussion at all levels from consultants to GPs to
specialist services.
13.
To work with the multidisciplinary team to provide early and pro-active CGAs to
patients who meet the criteria. The person centred holistic assessment will
include clinical, social, functional, emotional and cognitive elements as
documented within the CGA, this will require gathering and interpreting
information from various IT systems and sources, performing tests and analysing
results, recording collated information using a Single Assessment Pathway
14.
To utilise the CGA knowledge gained to initiate and facilitate person led early
discharge plans working in collaboration with hospital MDT and discharge teams
ensuring the patients needs are met and likelihood of unnecessary readmission
is reduced.
15.
The role requires understanding of the particular requirements of frail
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. 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.
16.
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.
17.
The post holder will support the role by 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.
Job description
Job responsibilities
1.
The post holder will be the lead specialist in frailty for community integrated
teams. This includes physical and functional assessment, clinical reasoning,
diagnostic reasoning and the ability to identify issues with polypharmacy in
frailty to action the necessary medication review. Using these skills will
assist in the recognition of early symptoms of frailty, disease exacerbation,
acute illness and injuries.
2.
An autonomous practitioner who will provide expert clinical case management for
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. Be responsible for facilitating efficient,
effective co-ordinated assessments and treatment for frail older adults.
3.
Undertakes specialist frailty assessment, plans and implements care in a
variety of settings, provides highly specialist advice to patients/clients,
carers, relatives and other professionals; maintains associated records.
4.
Develops and delivers specialist frailty education programmes to service users,
families and professionals.
5.
Key member of the Ageing Well Multidisciplinary Team (MDT), and lead
practitioner to support Livewell community integrated teams in completion of
comprehensive geriatric assessment, working in conjunction with primary care
network colleagues.
6.
Using referral criteria and an agreed case finding tool (Electronic Frailty
Index [eFI] or Rockwood score), identify and assess patients who are suitable
for a full CGA assessment.
7.
Completion of CGA including collateral social and past medical history from
patients, family, care providers, community and primary care services. Liaise
where appropriate with health and social care and other external agencies.
8.
Document full CGA and formulate an appropriate person-centred plan. Collaborate
with the 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.
9.
To be responsible for the advanced assessment, treatment and management of
patients. Negotiate, agree expectation and set appropriate, realistic and
individual goals in partnership with the patient, carer and colleagues
10.
Take a lead role by offering professional support within the MDT when dealing
with complex/urgent situations which can be emotionally challenging e.g.
terminal illness.
11.
[Where indicated] Initiate and ensure Advanced Care Planning and completion of
Treatment Escalation Plan (TEP) 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 Authority and
Organisational End of Life Strategy and NICE Clinical Guidelines.
12.
Make independent referrals for diagnostic tests and/or opinions and care which
requires open and informed discussion at all levels from consultants to GPs to
specialist services.
13.
To work with the multidisciplinary team to provide early and pro-active CGAs to
patients who meet the criteria. The person centred holistic assessment will
include clinical, social, functional, emotional and cognitive elements as
documented within the CGA, this will require gathering and interpreting
information from various IT systems and sources, performing tests and analysing
results, recording collated information using a Single Assessment Pathway
14.
To utilise the CGA knowledge gained to initiate and facilitate person led early
discharge plans working in collaboration with hospital MDT and discharge teams
ensuring the patients needs are met and likelihood of unnecessary readmission
is reduced.
15.
The role requires understanding of the particular requirements of frail
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. 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.
16.
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.
17.
The post holder will support the role by 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.
Person Specification
Qualifications
Essential
- Registered practitioner
- Professional knowledge acquired through degree supplemented by post graduate diploma with 3-5 years significant relevant experience.
- Specialist training and experience, short courses plus further specialist training
- Membership of the relevant Professional Body
- Evidence of recent professional development in an up-to-date portfolio
- Leadership and management qualification/training or evidence of experience in this area
Desirable
- Teaching qualification
- Additional clinical qualifications in Frailty/Older Persons Care
Experience
Essential
- Proven relevant post registration experience
- Experience of the management of patients living with frailty (predominantly older people)
- Experience of cross system and Multi-Disciplinary Team working
- Experience in managing teams.
- Experience in designing training packages relevant to role
- Previous experience/delivery of formal/informal teaching of patients and staff
Knowledge and skills
Essential
- Knowledge of Community Services/Third sector services suitable for frail patients
- Knowledge and understanding of legislation relevant to practice
- Experience of using electronic patient / service user record systems
- Ability to develop effective interpersonal relationships with colleagues in an MDT setting
- Ability to communicate in a variety of settings with patients of varying levels of understanding
- Ability to communicate unpleasant and sensitive information
- Able to manage own workload, plan the work of others and work autonomously
- Logical and good at problem solving.
- Operational/organisational skills and ability to work and prioritise and work under pressure
- Demonstrable knowledge of assessment and therapeutic interventions in area of specialism
- Skills and experience of developing specialist programmes of care for an individual or groups of patients/clients and of providing highly specialist advice
- Skills for assessing and interpreting specialist patient/client conditions in order to make a clinical judgement regarding diagnosis and interventions
- Skills to develop and deliver educational packages in frailty across the MDT
- Able to overcome barriers to understanding where there are physical or mental disabilities
- Ability to develop role to meet the changing needs of the service
Person Specification
Qualifications
Essential
- Registered practitioner
- Professional knowledge acquired through degree supplemented by post graduate diploma with 3-5 years significant relevant experience.
- Specialist training and experience, short courses plus further specialist training
- Membership of the relevant Professional Body
- Evidence of recent professional development in an up-to-date portfolio
- Leadership and management qualification/training or evidence of experience in this area
Desirable
- Teaching qualification
- Additional clinical qualifications in Frailty/Older Persons Care
Experience
Essential
- Proven relevant post registration experience
- Experience of the management of patients living with frailty (predominantly older people)
- Experience of cross system and Multi-Disciplinary Team working
- Experience in managing teams.
- Experience in designing training packages relevant to role
- Previous experience/delivery of formal/informal teaching of patients and staff
Knowledge and skills
Essential
- Knowledge of Community Services/Third sector services suitable for frail patients
- Knowledge and understanding of legislation relevant to practice
- Experience of using electronic patient / service user record systems
- Ability to develop effective interpersonal relationships with colleagues in an MDT setting
- Ability to communicate in a variety of settings with patients of varying levels of understanding
- Ability to communicate unpleasant and sensitive information
- Able to manage own workload, plan the work of others and work autonomously
- Logical and good at problem solving.
- Operational/organisational skills and ability to work and prioritise and work under pressure
- Demonstrable knowledge of assessment and therapeutic interventions in area of specialism
- Skills and experience of developing specialist programmes of care for an individual or groups of patients/clients and of providing highly specialist advice
- Skills for assessing and interpreting specialist patient/client conditions in order to make a clinical judgement regarding diagnosis and interventions
- Skills to develop and deliver educational packages in frailty across the MDT
- Able to overcome barriers to understanding where there are physical or mental disabilities
- Ability to develop role to meet the changing needs of the service
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
