Advanced Frailty Practitioner - ANP/Paramedic

• Undertake comprehensive clinical assessments of patients presenting with complex health needs, frailty and multiple long-term conditions.
• Exercise advanced clinical reasoning and decision-making to assess, diagnose, treat and manage patients independently within professional competence.
• Develop, implement and regularly review evidence-based management and treatment plans.
• Prescribe medications safely and appropriately in accordance with independent prescribing qualifications, professional standards and local prescribing guidance.
• Recognise clinical deterioration, red flags and safeguarding concerns, escalating appropriately.
• Assess and manage minor illnesses and acute presentations where appropriate to the postholder's clinical competence.

• Proactively identify and manage patients living with moderate and severe frailty.
• Undertake comprehensive frailty assessments, incorporating physical, psychological, functional and social care needs.
• Develop personalised care and support plans, including anticipatory and escalation planning where appropriate.
• Support patients to maintain independence and remain safely within their homes and communities.
• Identify patients at increased risk of deterioration, falls, hospital admission or readmission and coordinate timely interventions.
• Support medication reviews, falls prevention, rehabilitation planning and appropriate referrals to community services.
• Contribute to the identification and management of patients approaching the end of life, working collaboratively with GPs and specialist palliative care teams.
• Ensure patients and their families or carers are actively involved in decisions about their care.

• Undertake planned and clinically indicated home visits for housebound, frail and vulnerable patients.
• Assess patients within their home environments, identifying clinical, functional and social factors affecting their health and wellbeing.
• Initiate appropriate treatment, investigations, referrals and follow-up arrangements.
• Work closely with district nursing teams, community matrons, therapists, social care professionals and other community services.
• Recognise when urgent escalation or hospital assessment is required.

• Work collaboratively with GPs, Advanced Practitioners, Clinical Pharmacists, care coordinators and wider PCN teams.
• Participate in multidisciplinary team meetings and frailty case discussions.
• Coordinate care across primary, community, secondary and social care services.
• Support effective communication and information sharing between professionals involved in patient care.
• Facilitate timely referrals and follow-up to promote continuity of care and reduce duplication.
• Contribute to effective discharge planning and post-discharge reviews to reduce the risk of hospital readmission.

• Maintain accurate, timely and comprehensive clinical records using the practice's electronic clinical systems.
• Work in accordance with relevant professional codes, clinical guidelines, local policies and evidence-based practice.
• Maintain patient confidentiality and comply with information governance requirements.
• Participate in clinical audits, quality improvement initiatives, significant event reviews and service evaluations.
• Identify and appropriately escalate clinical risks, safeguarding concerns and incidents.
• Maintain professional registration, prescribing competency and continuing professional development.

• Contribute to the ongoing development of the PCN frailty service, supporting proactive, coordinated and person-centred models of care.
• Identify opportunities to improve patient pathways, clinical processes and multidisciplinary working.
• Support the development of effective systems for identifying, reviewing and monitoring patients living with frailty.
• Contribute to the achievement of relevant PCN and NHS service objectives.
• Promote effective use of healthcare resources while maintaining high standards of clinical care.
• Participate in relevant training, professional development and service improvement activities.

Essential

• Advanced clinical assessment, diagnostic reasoning and decision-making skills
• Ability to undertake comprehensive clinical and frailty assessments
• Sound knowledge of frailty, multimorbidity and long-term condition management
• Safe and effective independent prescribing skills
• Ability to recognise and appropriately manage clinical deterioration
• Excellent communication, organisational and clinical documentation skills
• Ability to manage an autonomous clinical caseload and prioritise competing demands
• Understanding of safeguarding, clinical governance and information governance
• Ability to work collaboratively across primary, community and secondary care

Desirable

• Knowledge of local community healthcare and social care pathways
• Experience of personalised care planning and anticipatory care approaches
• Knowledge of relevant PCN and NHS service specifications
• Experience supporting falls prevention and rehabilitation pathways
• Experience in service development and clinical pathway improvement
• Experience supporting or mentoring junior clinical colleagues

Essential

• Registered Nurse (NMC) or Paramedic (HCPC) with current UK registration
• Recognised advanced clinical practice qualification at postgraduate level, or equivalent evidenced advanced practice training and competence
• Independent prescribing qualification (V300 or recognised equivalent) with appropriate prescribing annotation
• Evidence of continuing professional development

Desirable

• Relevant postgraduate qualification in frailty, older people's care or advanced clinical practice
• MSc in Advanced Clinical Practice
• Advanced training in comprehensive geriatric assessment, palliative care or long-term condition management
• Leadership, mentorship or clinical education qualification

Essential

• Significant post-registration clinical experience, including autonomous advanced clinical practice
• Experience assessing and managing patients with complex health needs and multiple long-term conditions
• Experience managing frail, older or vulnerable patients
• Experience of independent clinical decision-making, diagnosis and treatment planning
• Experience working within multidisciplinary healthcare teams
• Experience of safeguarding and clinical risk management

Desirable

• Previous experience working within a Primary Care Network or GP practice
• Experience delivering a dedicated frailty service
• Experience undertaking home visits and community-based clinical assessments
• Experience coordinating multidisciplinary frailty meetings
• Experience contributing to clinical audits, quality improvement or service redesign
• Experience using EMIS Web, Docman or AccuRx

Essential

• Significant post-registration clinical experience, including autonomous advanced clinical practice
• Experience assessing and managing patients with complex health needs and multiple long-term conditions
• Experience managing frail, older or vulnerable patients
• Experience of independent clinical decision-making, diagnosis and treatment planning
• Experience working within multidisciplinary healthcare teams
• Experience of safeguarding and clinical risk management

Desirable

• Previous experience working within a Primary Care Network or GP practice
• Experience delivering a dedicated frailty service
• Experience undertaking home visits and community-based clinical assessments
• Experience coordinating multidisciplinary frailty meetings
• Experience contributing to clinical audits, quality improvement or service redesign
• Experience using EMIS Web, Docman or AccuRx