About this role
Job summary
The Enhanced Frailty Team, in conjunction with the wider multi-disciplinary team, comprises of a Consultant Geriatrician, Chief Medical Officer, Enhanced Frailty GPs, Enhanced Frailty Nurse Practitioners, and Frailty Care Coordinator / Prescribers.
The purpose of the Frailty Team is:
To provide integrated, pro-active care for people in Harrow aged 65 years of age or over, or identified as frail, with multiple complex long-term conditions, who require more intensive support and care in the community To reduce avoidable hospital admissions / re-admissions or A&E attendances To support Harrow GPs with intensive case management of these more complex, vulnerable patients to improve the health and wellbeing of patients by providing proactive, responsive and intensive case management
Main duties of the job
The Post Holder will be a highly competent individual, who will play a key role in co-ordinating the Frailty Team activities and act as a Social Prescriber for patients and their families / carers as needed. They will work with members of the team and other health and care providers to share information to jointly plan care and provide a streamlined service.
The post holder will be performance managed with clear objectives designed to evidence your success in delivering excellent patient satisfaction and health outcomes, supporting the Frailty Team patient caseload, developing colleagues skills, and lastly supporting patients to avoid unnecessary hospital admissions.
About us
Harrow Health CIC
Harrow Health CIC began in 2007 by a group of Harrow GPs, whose sole aim was to ensure patients receive a high quality clinical care service within the community. Over the years, Harrow Health has expanded. We now provide many clinical services, which include Mental Health Services, Elective Services, and our Whole Systems Integrated Care Services.
Our Vision:
To provide high quality patient care, enhancing patient experience by providing excellent clinical effectiveness in a safe environment; working in partnership to provide gold standard services and develop a sustainable future for the local health community.
Job description Job responsibilities
Main Responsibilities
Work with GP Surgeries to identify potential referrals to the Tier 2 Frailty ServiceWorking with Frailty Team colleagues, use risk stratification tools to identify patients at risk and ensure they receive assessment and care in a timely fashionSupport the Frailty Team in the delivery of Complex Care, coordinating care delivery between service providers as neededMake Social Prescribing referrals, as appropriateContribute to planned team huddles and multi-disciplinary team meetingsHold regular welfare calls with the patient / carerMaintain excellent working relationships with all those involved in the provision and development of services for those with long-term conditions, sharing regular updates of planned care and any changes when they occurWork closely with the Frailty Team and others involved in care delivery to ensure patients have relevant referrals and access in place; attend and liaise with the Frailty Team MDT groups, regularly attending case conferences and providing relevant updatesCommunication Skills
The post-holder will recognize the importance of effective communication within the team and will strive to:
Communicate with patients in a welcoming way, which is non-judgmental and respects patients feelings, circumstances, and rightsUtilise and demonstrate sensitive communication styles to ensure patients are fully informed of reasons for contact when contacting them for example, on welfare callsCommunicate highly sensitive patient information and progress effectively with other team members and outside relevant health and social care providers, as appropriateEnsure all documented notes are contemporaneous
Supporting Responsibilities
Quality
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 performanceParticipate in the management, review, and identification of learning from patient complaints and significant eventsDeliver evidence-based care according to the National Institute for Clinical Excellence (NICE) and Care Quality Commission (CQC) guidelines
Information Technology
Possess basic computing and keyboard skillsHave a good working knowledge of relevant areas of clinical systems and other programmes as appropriate to the roleDemonstrate a good working knowledge of the policy on information and clinical governance
Research and Audit
Contribute to the collection of data for research/audit purposesIdentify audit topics relevant to the Frailty Team
Professional and Educational Responsibilities
Ensure all Statutory and Mandatory training is completeAvail of all opportunities to develop both clinical knowledge and practical skills
Person Specification
Qualifications Essential
Maths and English at GCSE level or equivalent. Evidence of relevant experience in a health, social care, community, primary care or care-coordination environment. Willingness to undertake all required statutory and mandatory training. Good working knowledge of confidentiality, information governance and clinical governance.
Desirable
Social Prescribing qualification or relevant experience of making/working with social prescribing referrals. Relevant qualification or training in health and social care, care coordination, frailty, long-term conditions or a related field.
Experience Essential
Customer focused service delivery Team working Ability to deal with situations sensitively and appropriately, remaining polite and calm at all times
Desirable
Experience in change management Evidence of management experience / training
Personal Attributes Essential
Positive, professional and patient-centred approach. Compassionate, empathetic and respectful towards patients and carers. Able to remain calm and professional when dealing with challenging or sensitive situations. Flexible and willing to support colleagues and service requirements. Reliable, organised and able to work independently and as part of a team.
Desirable
Experience working with vulnerable adults or people with complex needs. Experience working in a community healthcare or social care environment.
Knowledge & Skills Essential
Good verbal and written communication skills. Excellent organisational and time management skills.
Desirable
Able to use electronic systems effectively. Ability to maintain accurate and timely records. Ability to communicate sensitively with patients, carers and professionals. Ability to prioritise and coordinate multiple tasks.
Employer details Employer name Harrow Health CIC
Address Harrow Health CIC- 2nd Floor
7 St John's Road
Harrow
HA1 2EY
United Kingdom
Employer's website https://www.harrowhealth.org.uk (Opens in a new tab)