About this role
Job summary
The post holder will support our PCN to provide seamless care to our patients. This will involve working closely with our practice teams, the community frailty team and the hospital discharge team as part of an integrated frailty service. Our aim is to support early discharge from hospital, prevent unnecessary readmission, as well as to be proactive in identifying and reviewing our patients who are severely frail. We also aim to support patients by providing both proactive and ongoing care following an acute episode and discharge from hospital.
Main duties of the job
This role will provide dedicated support to patients and their carers who are having multiple interactions with different health, care, and voluntary sector services. Their role will also improve the continuity of care by acting as a point of contact for patients, families and professionals who visit in their own home.
All patient GP records will be reviewed, and a risk stratification tool (eFI) will be used to identify those patients in the surgery with moderate to severe frailties. Patients can also be identified by the GP team or another health or social care provider as appropriate.
Each patients frailty and vulnerability risks will be reviewed by the service, with reference to the eFI (Electronic Frailty Index). The review will include Complete Geriatric Assessment, falls assessment, social and environmental situation. The frailty nurse will provide the patient with support with advanced care planning & RESPECT form, recognition of end-of-life status and the development and implementation of treatment escalation plans.
Patients will be encouraged and enabled to take on as much responsibility as they want in order to manage their own care, health and well being needs. Support will be provided to carers and families to recognise their needs as well
About us
Panacea PCN is a group of 7 GP Practices serving the population of Grimsby and Cleethorpes with a list size of 47000
Job description Job responsibilities
Clinical responsibilities
To assess, plan, implement and evaluate specialist treatment and care through personalised care plans to people on an allocated caseload; promoting independence and autonomy; working within a multi-disciplinary team. Advance own clinical knowledge, skill and competence based on current evidence through advanced educational programmes. Completing and sharing advanced care plans Partnership working with other providers to deliver seamless joined up care. Reviewing and making clinical decisions, including prioritisation of need. Provide highly specialist advice to others regarding the management and care of patients/service users. To demonstrate clinical effectiveness by use of evidence-based practice and outcome measures. Plan, implement and review health improvement programmes in a range of settings. Recognise, assess, and manage risk across the immediate and wider working environment and make appropriate decisions autonomously, ensuring statutory requirements are met. To be responsible for patient safety through knowledge of systems, legal requirements and understanding of litigation. To communicate effectively in verbal and written form in the exchange of highly complex, sensitive or contentious information in difficult situations using de-escalation, mediation, resolution and professional Duty of Candour. To evaluate care, taking appropriate action leading to improvement in quality standards through clinical audit, root cause analysis and dealing with complaints. Provision of support to carers considering what can put in place to support that persons mental health and wellbeing, by the use of tools to identify deterioration in wellbeing and mental state. Liaison between local organisations such as volunteering etc to provide services that can support the delivery of care within the patients own home. Referral to and attendance at MDTs involving a range of health and care professionals, from one or more organisations, working together to deliver comprehensive patient care. The benefits of such an approach can include improved health outcomes, enhanced satisfaction for the individual and a more efficient use of resources.
Responsibility for Information / Data
To maintain and ensure the highest quality of recording of patient data into the relevant record system in line with professional guidance. To maintain confidentiality and comply with required Data Protection and other IG requirements and best practice.
Professional Responsibilities
Ensure that personal performance meets job requirements, Professional Codes and standard Ensure the required level of IT competence required for the role to process, record, evaluate, analyse and report data. Demonstrate commitment to the role and to service improvement through developing relationships with key partners, innovative thinking and small scale project management. Provide a positive, compassionate role model to junior staff and colleagues to ensure the delivery of people centred care and the key components of compassionate care Create effective team work across professional boundaries using team building skills, creating common goals, and through engagement. Respect and apply the requirements of equality and diversity, promoting and role modelling these across the multi-disciplinary team.
Other Responsibilities
To provide holistic assessment of older adults living with frailty To participate in the delivery of education and training to staff within the PCN as appropriate. To undertake urgent visits to patients in their own homes. To be able to recognise deteriorating patients and to respond appropriately. To work as part of the frailty team to provide pro-active and enhanced clinical management for patients within their own homes to reduce admissions to hospital and urgent referrals to primary care. To work flexibly to meet the demands of the service and adapt to changing priorities within the working day/week
Person Specification
Experience Essential
Experience of managing change Demonstrable knowledge of assessment and therapeutic interventions in area of specialism Experience of developing specialist programmes of care for an individual or groups of patients/clients and of providing highly specialist advice Able to demonstrate specialist clinical reasoning skills to assimilate information in order to make a clinical judgement regarding diagnosis and intervention. Ability to prioritise and organise workload effectively
Desirable
Experience of working with older adults living with frailty Recent previous experience within a comparable role in the community
Qualifications Essential
Registered practitioner to degree/diploma level supplemented by post registration diploma level specialist training and/or short courses or demonstrable extensive experience in the relevant specialty Membership of the relevant Professional body Evidence of recent professional development in an up to date portfolio
Desirable
Completion of history taking and physical examination course Knowledge and understanding of NHS Strategy relevant to role
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.
UK Registration
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).
Employer details Employer name Panacea Collaborative
Address 65-69 Stirling Street
Grimsby
North East Lincolnshire
DN31 3AE
United Kingdom
Employer's website https://www.drmathewsgp.nhs.uk/ (Opens in a new tab)