The Enhanced Frailty Team, in conjunction with the wider multi-disciplinary team, comprises of a Consultant Geriatrician, Enhanced Frailty GPs, Enhanced Frailty Nurse Practitioner, Emergency Care Practitioner, Health and Social Care Coordinator, and Social Prescriber.
Harrow Enhanced Frailty Service
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 or re-admissions or A&E attendances.
To support Harrow Primary and Secondary Care 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 Enhanced Frailty Practitioner will provide clinical support to patients, supported by the wider Clinical team, to work autonomously holding their own caseload. Primary care provision rapidly changes, and the role is expected to evolve to reflect this.
Work in accordance with the National and Midwifery Council (NMC) Code of Conduct for Nurses, Health Care Professional Council, and the Scope of Professional Practice.
Actively network with Harrow Enhanced Practice Nurses to share and implement best practice and support case finding for the Harrow Frailty Service.
Support the Enhanced Frailty Team in the delivery of Complex Care.
To maintain excellent working relationships with all those involved in the provision and development of services for those with long-term conditions.
Attend all mandatory meetings such as Touch Point meetings and MDTs.
About us
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 Primary Care Services, Community Services, and our Whole Systems Integrated Care Services.
Job responsibilities
Harrow has one of the highest proportions of those aged 65 years and over amongst its neighbouring boroughs, at 15.7%. This is higher than London at 8.1%.
Local defined outcomes
Improve the health and wellbeing of our frail population, their Carers, and staff working in the service, wherever possible through evidence-based interventions.
Improve the detection and escalation of frailty, around which interventions can be planned and delivered.
Provide a multidisciplinary, holistic service that is cognizant of the broader determinants of health and well-being of people with frailty, allowing them to set and achieve their goals, and maintain their independence.
Improve the experience of health services for our frail population, their Carers, and staff working in the service.
Achieve system-wide financial savings, as patients are better supported to remain at home, and systems work in a more integrated way, reducing costs associated with duplication, fragmentation, non-elective hospital admissions, and hospital stays.
The service will:
Provide holistic, person-centred care.
Aspire to the highest standards of excellence and professionalism.
Embed quality improvement, learning, and development at the heart of the service.
Be at the centre of a neighbourhood-based, integrated approach to providing out-of-hospital care for the frail population in Harrow.
Population covered:
The Provider shall deliver the services to patients registered to a GP practice within the London Borough of Harrow who are aged 65+ or identified as frail, by their GP or the electronic frailty index (eFi).
Role Overview
The Enhanced Frailty Team, in conjunction with the wider multi-disciplinary team, comprises of a Consultant Geriatrician, Enhanced Frailty GPs, Enhanced Frailty Nurse Practitioner, Emergency Care Practitioner, Health and Social Care Coordinator, and Social Prescriber.
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.
Job Summary:
The Post Holder will be a highly competent health care professional, accountable for your own actions and responsible for providing enhanced evidence-based nursing care and case management for patients with frailty issues or long-term conditions.
The Enhanced Frailty Practitioner will provide clinical support to patients, supported by the wider Clinical team, to work autonomously holding their own caseload. Primary care provision rapidly changes, and the role is expected to evolve to reflect this.
You will be performance managed with clear appraisals 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 avoid unnecessary hospital admissions.
Main Responsibilities
Work in accordance with the National and Midwifery Council (NMC) Code of Conduct for Nurses / Health Care Professional Council and the Scope of Professional Practice.
Actively network with Harrow Enhanced Practice Nurses to share and implement best practice and support case finding for the Harrow Frailty Service.
Support the Enhanced Frailty Team in the delivery of Complex Care.
To maintain excellent working relationships with all those involved in the provision and development of services for those with long-term conditions.
Attend all mandatory meetings such as Touch Point meetings and MDTs.
Managing Patients with Frailty issues
Identify, assess, and signpost patients on the Frailty Team list with complex long-term conditions, and nursing needs, in conjunction with GPs, district and specialist nurses, and other lead clinicians.
Develop disease care management plans including self-care strategies to meet individuals' complex health and nursing needs.
Provide highly specialist care and advice - this could include diagnosis, management and treatment plans, and referrals as appropriate.
Manage patients' medicines and ensure adherence, in conjunction with GPs, consultants, and specialist nurses ensuring approaches are consistent with standards, protocols, and legislation.
Working closely with the Health and Social Care Coordinator to ensure patients have relevant referrals and access in place to Harrow Community Services, attend and liaise with the Frailty Team MDT groups, regularly attending case conferences and providing relevant updates.
Communication Skills
The post-holder will recognize the importance of effective communication within the team and will strive to:
Utilize and demonstrate sensitive communication styles to ensure patients are fully informed and consent to treatment.
Communicate highly sensitive patient information and progress effectively with other team members and outside relevant health and social care providers.
Communicate with patients in a welcoming way, which is non-judgemental and respects patients' feelings, circumstances, and rights.
Ensure all documented notes are contemporaneous.
Supporting Responsibilities
Quality
The post-holder will strive to improve the quality of nursing within the Frailty Team, and will:
* Ensure clinical practice is safe and effective and remains within the boundaries of competence and acknowledges limitations.
* Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the team's performance.
* Participate in the management, review, and identifying learning from patient complaints and significant events.
* Deliver 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 skills.
Have a good working knowledge of relevant areas of clinical systems and other programmes as appropriate to the role.
Demonstrate a good working knowledge of the policy on information and clinical governance.
Research and Audit
* Contribute to the collection of data for research/audit purposes.
* Identify audit topics relevant to the Frailty Team.
Professional and Educational Responsibilities
Ensure registration and revalidation is kept up to date.
Ensure all Statutory and Mandatory training is complete.
Avail of all opportunities to develop both clinical knowledge and practical skills.
Person Specification
Qualifications
* BSc Nursing OR
* Non-Medical Prescribing Qualification
Skills and Knowledge
* Evidence of cross boundary multi-agency working.
* Case Management and Progression.
* Wound care including compression bandaging.
* Catheterisation - Male and female, supra pubic.
* Trial without catheter (TWOC).
* Palliative Care Syringe Driver administration of palliative/end of life medications.
* End of Life Care.
Experience
* Experience of working in a primary care or community setting.
* Experience of working in a multidisciplinary setting.
* Experience of working with multiple complex comorbidities.
* Involvement in research.
* Working with frail patients.
* Geriatric nursing.
* Evidence of management experience.
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.
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