Exciting opportunity to join an enthusiastic and good-humoured Primary Care Network Frailty Care Team looking for a like-minded Frailty Clinical Practitioner to join our team. To work as an autonomous practitioner, providing expert clinical case management for people with frailty with intensive, chronic, transitory and sometimes acute biopsychosocial needs who are at risk of increased loss of independence that may result in loss of quality of life, avoidable hospital admission or unnecessary length of stay. As a Frailty Clinical Practitioner and Independent prescriber your role will be crucial in preventing increased loss of independence, avoiding unnecessary hospital admissions and supporting the Frailty Care Team in the delivery of the Enhanced Care in Care Homes contract for the PCN. You will manage a caseload of individuals identified as needing support to improve or maintain their quality of life and undertake weekly care home ward rounds independently. You will be part of an exciting and innovative quality improvement project with a support MDT in the beautiful setting of the North Cotswolds.
Main duties of the job
Provide expert clinical case management for people with frailty who may have multiple long-term conditions and are at risk of deteriorating health that may result in declining clinical quality of life or avoidable hospital admission, or unnecessary length of hospital stay. Undertake the weekly care home and nursing home GP ward rounds across the North Cotswold PCN care home group. Develop relationships with staff within the neighbourhood team including practices, ICT, Older Peoples Mental Health service, Rapid Response and adult social care collaborating with them on a day-to-day basis. Undertake comprehensive geriatric assessment of the physical, functional and psycho-social care needs of people with frailty who may also have complex chronic conditions. Develop a person-led evidence-based holistic health and social care plan in conjunction with patients and their relatives and carers, medical and other health and social care colleagues. About us
North Cotswold Primary Care Network is an NHS collaboration between 5 GP Practices, all with a CQC overall good rating - Chipping Campden Surgery, Cotswold Medical Practice, Mann Cottage Surgery, Stow Surgery and The White House Surgery. Our surgery teams are working closely with each other, enjoying the ability to share expertise and resources, to develop new services. Our vision is to continue to improve the quality of care that we provide in alignment with the need of our patient population. As part of a PCN we are able to take advantage of additional staff roles that are now available to support all of our patients. Our Frailty Care Team is a multi-disciplinary team of ANPs, Clinical Pharmacists, Community matrons, Health and Wellbeing Coaches and Care Coordinators currently using a quality improvement approach to improve care and services to the population on our frailty case load which includes patients in care and nursing homes across the PCN locality. This is an exciting opportunity to join our team and support the patients in our care home setting and in their own homes. Job responsibilities
Provide expert clinical case management for people with frailty who may have multiple long-term conditions and are at risk of deteriorating health that may result in declining clinical quality of life or avoidable hospital admission, or unnecessary length of hospital stay. Undertake the weekly care home and nursing home GP ward rounds across the North Cotswold PCN care home group. Support and work with close family, carers and wider family members. Develop relationships with staff within the neighbourhood team including practices, ICT, Older Peoples Mental Health service, Rapid Response and adult social care collaborating with them on a day-to-day basis. Undertake comprehensive geriatric assessment of the physical, functional and psycho-social care needs of people with frailty who may also have complex chronic conditions. Develop a person-led evidence-based holistic health and social care plan in conjunction with patients and their relatives and carers, medical and other health and social care colleagues. Person Specification
Other attributes
Ability to develop and maintain effective working relationships with colleagues and other partners. Ability to work autonomously with clear recognition of own limitations and when to seek advice. MDT approach to management of complex patients. Ability to work flexibly. Driving. Must be proficient in clinical skills required for area of practice. Knowledge of North Cotswolds area. Experience
Experience of working in primary care. Experience of working in community team. Qualifications
Educated to Degree level or equivalent competencies in health-related subjects Registered Professional Body. Advanced Physical Assessment & Clinical Reasoning modules/course. Knowledge in managing patients with complex medical needs, long term conditions management and palliative care. Knowledge of current and emerging health and social care economy specifically the social care agenda. Knowledge of governance and risk strategies and their application in a community setting. Frailty competency broad experience working with elderly frail patients across pathway. Knowledge of clinical systems SystmOne and/or EMIS. Previous experience of working in primary care setting. Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions. Full-time, Part-time, Job share, Flexible working.
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Provide expert clinical case management for people with frailty who may have multiple long-term conditions and are at risk of deteriorating health that may result in declining clinical quality of life or avoidable hospital admission, or unnecessary length of hospital stay. Undertake the weekly care home and nursing home GP ward rounds across the North Cotswold PCN care home group. Develop relationships with staff within the neighbourhood team including practices, ICT, Older Peoples Mental Health service, Rapid Response and adult social care collaborating with them on a day-to-day basis. Undertake comprehensive geriatric assessment of the physical, functional and psycho-social care needs of people with frailty who may also have complex chronic conditions. Develop a person-led evidence-based holistic health and social care plan in conjunction with patients and their relatives and carers, medical and other health and social care colleagues. About us
North Cotswold Primary Care Network is an NHS collaboration between 5 GP Practices, all with a CQC overall good rating - Chipping Campden Surgery, Cotswold Medical Practice, Mann Cottage Surgery, Stow Surgery and The White House Surgery. Our surgery teams are working closely with each other, enjoying the ability to share expertise and resources, to develop new services. Our vision is to continue to improve the quality of care that we provide in alignment with the need of our patient population. As part of a PCN we are able to take advantage of additional staff roles that are now available to support all of our patients. Our Frailty Care Team is a multi-disciplinary team of ANPs, Clinical Pharmacists, Community matrons, Health and Wellbeing Coaches and Care Coordinators currently using a quality improvement approach to improve care and services to the population on our frailty case load which includes patients in care and nursing homes across the PCN locality. This is an exciting opportunity to join our team and support the patients in our care home setting and in their own homes. Job responsibilities
Provide expert clinical case management for people with frailty who may have multiple long-term conditions and are at risk of deteriorating health that may result in declining clinical quality of life or avoidable hospital admission, or unnecessary length of hospital stay. Undertake the weekly care home and nursing home GP ward rounds across the North Cotswold PCN care home group. Support and work with close family, carers and wider family members. Develop relationships with staff within the neighbourhood team including practices, ICT, Older Peoples Mental Health service, Rapid Response and adult social care collaborating with them on a day-to-day basis. Undertake comprehensive geriatric assessment of the physical, functional and psycho-social care needs of people with frailty who may also have complex chronic conditions. Develop a person-led evidence-based holistic health and social care plan in conjunction with patients and their relatives and carers, medical and other health and social care colleagues. Person Specification
Other attributes
Ability to develop and maintain effective working relationships with colleagues and other partners. Ability to work autonomously with clear recognition of own limitations and when to seek advice. MDT approach to management of complex patients. Ability to work flexibly. Driving. Must be proficient in clinical skills required for area of practice. Knowledge of North Cotswolds area. Experience
Experience of working in primary care. Experience of working in community team. Qualifications
Educated to Degree level or equivalent competencies in health-related subjects Registered Professional Body. Advanced Physical Assessment & Clinical Reasoning modules/course. Knowledge in managing patients with complex medical needs, long term conditions management and palliative care. Knowledge of current and emerging health and social care economy specifically the social care agenda. Knowledge of governance and risk strategies and their application in a community setting. Frailty competency broad experience working with elderly frail patients across pathway. Knowledge of clinical systems SystmOne and/or EMIS. Previous experience of working in primary care setting. Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions. Full-time, Part-time, Job share, Flexible working.
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