Primary Care Network Frailty Practitioner

• Substantial post-registration experience working with people living with frailty, multimorbidity or complex needs.
• Experience of holistic assessment, care planning and clinical or functional risk management.
• The ability to recognise deterioration and make safe, timely decisions within your competence.
• Experience of effective multidisciplinary and cross-organisational working.
• Strong communication skills, including the ability to discuss complex and sensitive matters with patients, carers and professionals.
• Knowledge of adult safeguarding, consent, the Mental Capacity Act and information governance.
• The ability to prioritise and manage a complex community caseload.
• The ability to travel independently throughout the Saltash and Torpoint, and Liskeard and Looe areas and undertake home visits.

• To identify those living with frailty within the PCN, utilising the Rockwood scoring system or other identified method.
• To support the elderly to age healthier, reducing progression of frailty and risks associated with it where possible.
• To support them to make informed choices as to their health and welfare.
• To attend and lead MDTs and work collaboratively with neighbourhood teams to support elderly and carers.
• Reduce emergency hospital admission, readmission and try to reduce care burden.
• Support early discharge planning
• To identify those likely to be within their last year of life and support them to plan for their future needs.
• Develop shared care and support plans by involving older people living with frailty, their families and carers throughout all stages of progression.
• Early identification and treatment of Delirium.

• Develop, implement and evaluate a seamless Frailty support service across the PCN, working with community and secondary care where appropriate, and aimed at continuously improving standards of patient care and wider multi-disciplinary team working.
• Where appropriate, support the development of discharge and contingency plans with relevant professionals to arrange on-going care in residential, care home, hospital, community settings and at home
• Periodically review, evaluate and change rehabilitation programmes to rebuild lost skills and restore confidence
• Advise on home, and workplace environmental alterations, such as adjustments for wheelchair access, technological needs, and ergonomic support
• Advise patients, and their families or carers, on specialist equipment and organisations that can help with daily activities
• Assist patients to adapt to and manage their physical and mental health long-term conditions, through the teaching of coping strategies; and assess, plan, implement, and evaluate treatment plans, with an aim to increase patients productivity and self-care
• Ensure delivery of best practice in clinical practice, caseload management, education, research, and audit, to achieve corporate PCN and local population objectives.
• Advise practices of workflow and develop SOPs for team and practices to follow and implement, particularly Personalised Care Planning, utilising best practice.

• Ensure MDTs adhere to the Gold Standard Framework and lead MDT development and best practice across the PCN.
• Ensure the right people are involved in MDTs from the East Cornwall Neighbourhood teams and PCN teams.
• Participate in GP huddles and any other PCN/Partnership MDT and promotes effective ways of working
• Exercise a critical understanding of personal scope of practice and to identify when a patient requires escalation or referring on to other services.
• Develop effective working relationships with the Palliative Care Team and embed new processes and ways of working if required, to avoid duplication and to enhance the patient and family experience.

• Work with patients through a shared-decision making approach to plan realistic, outcomes-focused goals
• Coordinate and support the provision of Personalised Care Plans; Treatment Escalation Plans; End of Life Plans
• Undertake both verbal and non-verbal communication methods to address the needs of patients that have communication difficulties
• Communicate effectively with other team members
• Communicates effectively and appropriately with patients and carers complex and sensitive information regarding diagnosis, pathology and prognosis
• Recognise peoples needs for alternative methods of communication and responds accordingly
• Develop relationships and a collaborative working approach across the PCN supporting the integration of pathways in primary care.

• Undertake clinical audits of in areas directed by the PCN, feedback the results and implement changes in conjunction with the practice teams.
• Demonstrates ability to identify and resolve risk management issues according to policy/protocol
• Follows professional and organisational policies/procedures relating to performance management
• Represents the Frailty service on relevant committees and meetings, as a lead clinician, provide input in relation to specialist issues and clinical matters as required.

• 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 skills
• Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards
• Reporting potential risks identified.

• Acting in a way that recognises 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.

• Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development.
• Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work.

• Alert other team members to issues of Clinical Governance issues, quality and risk; participate in any risk reviews
• 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. He/she will also contribute to the overall team-working of the PCN putting the needs of the PCN first.
• Contribution towards practices CQC compliance rating of GOOD or above.

Essential

• Demonstrates general skills and knowledge in core areas
• Experienced in developing and implementing Personalised Care Plans
• Is able to plan, manage, monitor, advise and review general frailty care programmes for patients in core areas, including disease states/ long term conditions identified by local Needs Assessment
• Demonstrates accountability for delivering professional expertise and direct service provision
• Able to follow legal, ethical, professional and organisational policies/procedures and codes of conduct.
• Full driving licence

Essential

• Demonstrates self-development through continuous professional development activity
• Demonstrates an understanding of current educational policies relevant to working areas of practice and keeps up to date with relevant clinical practice
• Ensures appropriate clinical supervision is in place to support development
• Enrolled into review and appraisal systems within PCN.

Essential

• Operate as a full member of the primary care team, including contributing service evaluation/improvement and research activity
• Manage and co-ordinate the care that individual patients receive, including through liaising with other members of the MDT and with patients' carers
• Facilitate primary care activity, with a strong emphasis on prevention and early intervention, including through the delivery of public health advice (e.g. relating to physical activity, weight management and smoking cessation)
• Contribute to the use of healthcare technologies to optimise the integration of service delivery (across teams, sectors and settings) and patients access and continuity of care
• Contribute to the development of primary care teams, including through contributing to others' learning.