Advanced Clinical Practitioner - Frailty

The successful candidate

should be an experienced practitioner who will

work in partnership with other health professionals in supporting frail

patients and providing holistic patient care. They will act within their

professional boundaries and competencies, assessing, planning &

implementing patient care.

They will participate in

MDT meetings to discuss patients that the Ageing Well Team are supporting. As

a result, they must have high level

communication/interpersonal skills to negotiate & establish collaborative

partnerships with patients & care professionals and have enthusiasm &

the ability to use their own initiative.

To visit clients who meet the Frailty assessment

criteria within their usual place of residence.

To assess and identify the health needs of

patients who are frail and who may have long-term conditions.

To undertake and coordinate Comprehensive

Geriatric Assessments (CGA), within professional competence, covering physical

health, medicines, cognition, mood, mobility, falls risk, nutrition,

continence, functional ability, social circumstances and future care wishes.

To use CGA findings to develop, document and

review person-centered, strengths-based care and support plans with patients,

carers and the multidisciplinary team, escalating clinical concerns

appropriately.

To provide clinical leadership, guidance and

support to care coordinators, including advice on patient care, risk

management, escalation and effective multidisciplinary working within agreed

professional boundaries.

To assess, plan, implement and evaluate

programmes of care to address the identified needs of patients identified as

being frail and/or those with long-term conditions.

To support the development of patients

individual Personal Health and Social Care Plans.

Develop disease specific patient information

and education to support patients self care.

Participate in education &

staff development, including specialised CPD relevant to Frailty and Dementia

and actively participate in regular supervision.

Participate in regular MDT

meetings and complex case management discussions.

Employed by Selby Prime Care Ltd but subcontracted to Selby Town PCN,

this is a role to support patients across Selby Town PCN.

works over four practice sites (Beech Tree Surgery, Escrick Surgery,

Posterngate Surgery and Scott Road Medical Centre) a local voluntary sector

site & our local community hospital.

has a Clinical Director, two Clinical Lead GPs and is managed by the PCN

Operations Manager & Business Manager. We work in increasingly

collaborative partnerships across several workstreams, which include important

priority areas of mental health, frailty, urgent care and health inequalities.

Our team consists of a diverse multi-professional workforce which includes

pharmacists, MSK practitioners, mental health workers, care coordinators,

social prescribing link workers, a frailty therapy team, an urgent care

coordinator, UCPs, paramedics, ACPs, a transformation lead, a digital lead,

health & wellbeing coach.

Other requirements

Essential: - Please see attached for full job description and person specification.

Experience

Qualifications