Frailty Community Specialist Nurse

Job summary

Are you ready to be at the forefront of addressing the challenges posed by our frail and ageing population and make a lasting impact on the NHS?

We are seeking a dedicated and passionate Frailty Community Specialise Nurse to join our dynamic team and work closely with Primary Care Networks, integrating with the wider community nursing teams. As a Frailty Nurse, you will play a vital role in improving patient outcomes and shaping the future of healthcare provided to our ageing population.

Frailty is a long-term condition and a clinically recognised state of increased vulnerability among older adults. With an increasingly ageing population, Primary Care Networks and Sunderland Community Nursing Teams are joining forces to develop an integrated frailty team.

Advanced communication, problem-solving and decision-making skills will be used to assess and provide on-going patient care. Working within local and nationally agreed protocols and guidelines, the Frailty Nurse exercises independent judgement to assess, investigate, diagnose, plan, implement and evaluate the clinical care and management of community patients.

The post holder will be part of a team that leads non-medical models of care across primary and community-based settings, including care homes and within community teams. The Frailty Nurse will play a crucial role in step up, step down and proactive care through timely assessment, referral, responsive intervention and care planning.

Main duties of the job

Brief Responsibilities:

• Collaborate with Primary Care Networks and a diverse multidisciplinary team to develop and implement comprehensive care plans for frail patients.
• Work closely with the wider Frailty Team such as the Frailty Advanced Clinical Practitioners, Community Frailty Team, Social Prescribing , Social Workers and General Practice Teams
• Conduct thorough geriatric assessments to identify the unique physical, cognitive, and psychosocial needs of the ageing population.
• Provide expert clinical assessment and management of complex medical conditions associated with frailty, including falls, polypharmacy, and cognitive impairment.
• Support the development of and implement innovative strategies to optimise care and enhance the well-being of frail patients, all while considering the impact on the NHS.

Support primary care practices in identifying and managing patients at risk of frailty, and proactively intervene to prevent complications,playing a lead role in the MDT focussing on ageing well and frailty

Foster effective communication and coordination between primary care, community services, and secondary care services to ensure seamless patient care.

About us

For the second year in a row, Sunderland GP Alliance has been listed in The Sunday Times Best Places to Work and Better Health At Work - Gold Award, offering 33 days annual leave plus many other benefits.

Sunderland GP Alliance is owned by the GP Practices of Sunderland and helps GPs work collaboratively for the benefits of patients and staff. We are not-for-profit organisation, ensuring any surplus is reinvested back into better services for patients.