Advanced Care Practitioner - Frailty

Work using FEAT and champion evidence-base interventions

Conduct comprehensive geriatric assessments

Monitor medication use and adjust treatment plans as

required

Exercise advanced clinical reasoning to diagnose, treat, and

manage patients without direct input from a medical practitioner, recognising

own professional boundaries and seeking senior clinical support when required.

Provide expert management of frailty syndromes

Escalate concerns appropriately

Identify when clinical presentations fall outside of scope

of practice and escalate appropriately to senior clinicians.

Work closely with GPs, OTs, Physios, Care Co-ordinators,

Social Prescribers and Community Nursing Team

Attend the MDT meetings and case reviews

Support patients and families

Promote lifestyle self management strategies to optimise

health and independence

Carry out clinical decision making such as diagnosing

Completing proactive clinical management plans for care home

residents

Conduct regular care plan reviews

Identify patients in need of palliative support and

facilitate advanced care planning discussions with patients and families

Communicating and caring for patients who have reduced

understanding and insight

Participate in weekly enhanced care home reviews

Undertake daily acute care home visits identifying clinical

emergencies or deteriorating patients, ensuring appropriate action

Participate in regular clinical supervision and reflection

discussions

Main Duties and Responsibilities

Work using FEAT and champion evidence-base interventions

Conduct comprehensive geriatric assessments using

appropriate tools

Monitor medication use and adjust treatment plans as

required, autonomously working within scope of practice and in line with

prescribing competencies.

Exercise advanced clinical reasoning to diagnose, treat, and

manage patients without direct input from a medical practitioner, recognising

own professional boundaries and seeking senior clinical support when required.

Provide expert management of frailty syndromes, dementia,

delirium, polypharmacy, falls risk and end of life needs.

Escalate concerns appropriately and initiate urgent or

emergency interventions when required.

Identify when clinical presentations fall outside of scope

of practice and escalate appropriately to GP or senior clinicians.

Work closely with GPs, Occupational Therapists,

Physiotherapists, Care Co-ordinators, Social Prescribers and Community Nursing

Team

Attend the MDT meetings and case reviews

Support patients and families in understanding and managing

frailty

Promote lifestyle and self management strategies to optimise

health and independence

Functions at a high level to carry out clinical decision

making such as diagnosing and managing patients without input from a medical

practitioner remaining within scope of a professional practice.

Functions at a high level in relation to communication

skills through patient consultation and nursing assessment of physical,

psychological and social needs.

Completing proactive, individualised clinical management

plans for care home residents improving their health experience and reducing

unnecessary and potentially harmful hospital admissions

Conduct regular care plan reviews

Identify patients in need of palliative support and

facilitate advanced care planning discussions with patients and families

Communicating with distressed/anxious/worried patients and

relatives

Caring for patients and relatives following receipt of bad

news and supporting them in identifying realistic expectations in relation to

clinical conditions

Communicating and caring for patients who have reduced

understanding and insight due to cognitive impairments

Participate/lead weekly enhanced care home reviews

Undertake daily acute care home visits requested through our

clinical triage system identifying clinical emergencies, deteriorating patients

or patients at risk of deterioration ensuring appropriate action

Participate in regular clinical supervision, reflective

practice and case-based discussions to maintain safe, effective and autonomous

practice.

Confidentiality

In the course of seeking treatment, patients entrust us

with, or allow us to gather, sensitive information in relation to their health

and other matters. They do so in confidence and have the right to expect that

staff will respect their privacy and act appropriately.

In the performance of the duties outlined in this Job

Description, the post-holder may have access to confidential information

relating to patients and their carers, Practice staff and other healthcare

workers. They may also have access to information relating to the Practice as a

business organisation. All such information from any source is to be regarded

as strictly confidential.

Information relating to patients, carers, colleagues, other

healthcare workers or the business of the Practice may only be divulged to

authorised persons in accordance with the Practice policies and procedures

relating to confidentiality and the protection of personal and sensitive data

Health & Safety

The post-holder will assist in promoting and maintaining

their own and others health, safety and security as defined in the practice

Health & Safety policy, the practice Health & Safety manual, and the

practice Infection Control policy and published procedures. This will include:

Using personal security systems within the workplace

according to practice guidelines

Identifying the risks involved in work activities and

undertaking such activities in a way that manages those risks

Making effective use of training to update knowledge and

Using appropriate infection control procedures, maintaining

work areas in a tidy and safe way and free from hazards

Actively reporting of health and safety hazards and

infection hazards immediately when recognised

Keeping own work areas and general / patient areas generally

clean, assisting in the maintenance of general standards of cleanliness

consistent with the scope of the job holders role

Undertaking periodic infection control training (minimum

annually)

Reporting potential risks identified

Equality and Diversity

The post-holder will support the equality, diversity and

rights of patients, carers and colleagues, to include acting in a way that

recognizes the importance of peoples rights, interpreting them in a way that is

consistent with Practice procedures and policies, and current legislation.

Respecting the privacy, dignity, needs and beliefs of patients, carers and

colleagues. Behaving in a manner which is welcoming to and of the individual,

is non-judgmental and respects their circumstances, feelings priorities and

right.

Personal/Professional Development

The post holder will participate in all training programmes

implemented by the Practice, including annual performance reviews and

competency assessments, and will take responsibility for their own ongoing

development, learning and performance.

They will maintain a comprehensive professional portfolio

demonstrating autonomous clinical practice, clinical supervision, CPD and

reflective learning, ensuring that clinical competencies required for safe

autonomous practice in frailty care are continually met.

The post holder will contribute to clinical governance

activities such as audits, incident reviews and quality improvement

initiatives, while engaging in regular clinical supervision and reflective

discussions to support safe, accountable practice. They will also support the

development of colleagues by sharing specialist frailty knowledge, offering

mentorship and demonstrating skills and activities to others undertaking

similar work

Quality

The post-holder will strive to maintain quality within the

Practice and will assess own performance and take accountability for own

actions, either directly or under supervision. Contribute to the effectiveness

of the team by reflecting on own and team activities and making suggestions on

ways to improve and enhance the teams performance. Work effectively with

individuals in other agencies to meet patients needs. Effectively manage own

time, workload and resources

Communication

The post-holder should recognise the importance of effective

communication within the team and will strive to communicate effectively with

other team members, communicate effectively with patients and carers and

recognise peoples needs for alternative methods of communication and respond

accordingly.

NCPC (North Cumbria Primary Care) was established in August

2019 in response to an increasingly fragile general practice provision within

North Cumbria. NCPCs vision is to bring practices together to develop a

sustainable, fully integrated primary care- built locally and delivered

together.

The Copeland NCPC area consists of 3 major practices,

Fellview Health Care, Lowther Medical Centre and Seascale Health Centre as well

as a shared PCN (Primary Care Network) which delivers services to patients

across all 3 practices.

We are a not-for-profit company with all money we receive in

funding and other business activities going towards supporting the

organisation, our staff, and our services

Essential Criteria