Harrow has one of the highest proportion 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 G 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-admission 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: Utilise 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 teams 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 programme as appropriate to 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