Job role To work closely with the UCR team & Clinical Leads for frailty, Community Nursing, Frailty GPs, Adult Social Care, community services and the third sector to provide fast reactive services for patients with decompensated frailty and ensure rapid delivery of treatment, care planning to support acute hospital admission avoidance where appropriate with a focus on the 9 Common Critical Conditions- Falls; Decompensation of Frailty; Reduced Function/Decondition/reduced mobility; Urgent equipment provision, Confusion / Delirium, Palliative / EOL crisis support; Urgent Catheter Care, Urgent support for diabetes; Unpaid Carer breakdown. To provide advanced assessment and care planning, including history taking and physical assessment for patients with frailty. To work closely with the frailty GPs, Advanced Clinical Practitioners & Clinical Leads for UCR & Frailty, adult social care and the third sector carers and patients to assist in proactively identifying and managing patients with frailty and supporting them and their carers in the development and delivery of personalised care plans. To provide strong holistic assessment and treatment planning of patients with frailty, without direct supervision. To work in conjunction with a wide range of clinical colleagues and specifically, primary care and community teams and Social Care professionals, leading and facilitating a patient or client focused, co-ordinated case management approach across primary and secondary care for people who are most vulnerable to, and at high risk of repeat admission to hospital. The UCR clinician will provide expertise within their professional discipline, to the wider team. 1.10 Advise on the promotion of health and prevention of illness and provide information to individuals and groups to prevent disease, where possible. Recognise situations that may be detrimental to health for example housing, social and economic factors and refer to an appropriate agency and liaise with members of the Community Care Team. 1.11 To provide case management using extended skills where appropriately trained to avoid hospital admission and manage sometimes complex clinical needs in the community setting. 1.12To provide assessment of patients, using analytical and judgment skills. To provide appropriate patient centred treatment using evidence-based practice where-ever possible. Patients will present with acute or chronic conditions and complex multi-system pathologies e.g. neuro, respiratory conditions, orthopaedic rehabilitation and age related deterioration. 1.13To devise effective, personalised plans of care for each patient with specific therapeutic knowledge, recognizing him or her as an individual. The plan of care, which has been developed in conjunction with the patient, carer, and relevant others, should be outcome based and ensure appropriate pathways of care and communication via liaison and referral to other agencies as required. 1.14The goals and objectives of any intervention are clearly established and negotiated, and where appropriate can be assessed through use of outcome measures/ objective markers. 1.15 To provide a holistic and therapeutic treatment programme or where appropriate direct the intervention as necessary through UCR Band 5 Clinicians, Community Rehab Assistants, HCAs or other members of the multi-disciplinary team