Frailty & Tracker Hca

Monitor scanned reports of falls patients. Contact patients after referral from Doctors, Practice Nurses, District Nurses; and to be aware of other avenues that may identify a vulnerable patient. Follow up patient admission/discharges with a support phone call. Provide information to patients on lifestyle/intermediary care/benefits helping to raise awareness of health and well-being and how it can be promoted.

Keep stock of tracker leaflets and outside agency leaflets. Refer to and liaise with social services, fallsclinic, occupational therapy, and other intermediaries to assist patients. Carry out blood tests and blood pressures, memory assessments & perform MUST procedures and new guidelines. Complete templates on the medical system and ensure all contact coded appropriately on the medical system.

Assisting with the collection and collation of data on needs related to health and well-being. Participate in monthly clinical meetings and MDT meetings. To practice autonomously with your extended knowledge and skill In conjunction with the Frailty lead GP, use the EFi search & your clinical knowledge to determine the patients Rockwood score and degree of frailty. This in turn will determine the practice frailty register Perform annual clinical review in line with patients birthday months, or earlier as clinically indicated.

Within the frailty assessments provide treatment, preventative care, screening and education to patients In conjunction with the Frailty lead GP, undertake baseline geriatric assessments for patients identified as severely frail by providing a comprehensive health assessment Enter any relevant information on to the Dorset Care Plan, meeting the Frailty register guidelines as clinically indicated. Discussing daily with the on call team any patients on the sudden and serious list which you may be aware of, and where possible deal with their acute needs. Do your utmost, with your experience and skill of these patients, to prevent admission to hospital and implement the patients wishes as highlighted in the Dorset Care plan With the patients concordance manage their journey, in collaboration with other agencies, with the aim to prevent hospital admission. Manage your own work load effectively to meet the demand of the surgery and patients.

Accept referrals from all areas of the MDT, reception, prescription clerks and the pharmacy and any other areas who may highlight concern for the frailer patients seeing areas of concerns that others may not see. HEALTH CARE ASSISTANT Job Summary: Working under the direct supervision of the Frailty lead GP and strictly in accordance with specific Practice guidelines and protocols, the Healthcare Assistant will assist the Practice clinical team in the provision and delivery of prescribed programmes of patient care: Perform routine BP and Pulse checks notifying clinician of any significant concerns. Perform routine blood tests Perform memory screening signposting to clinician for further assessments and/or referrals. Assisting in the assessment and surveillance of patients health and well-being.

Administer vaccines under a Patient Specific Direction Administration and professional responsibilities Participate in the administrative and professional responsibilities of the practice team. Ensure accurate and legible notes of all consultations and treatments are recorded in the patients notes. Ensure the clinical computer system is kept up to date with accurate details recorded. Ensure appropriate items of service claims are made accurately, reporting any problems to the practice manager.

Ensure accurate completion of all necessary documentation associated with patient health care and registration with the practice. Ensure collection and maintenance of statistical information required for regular and ad hoc reports. Attend and participate in practice meetings as required. Assist in formulation of practice philosophy, strategy and policy.

To assist in seasonal and special projects as requested e.g. flu campaign, smoking cessation Student/staff education and training Participate in the education and training of students of all disciplines and the induction of all members of practice staff with nursing interest. Liaison Maintain effective liaison with other agencies and staff concerned with patient care and with all other disciplines within the practice, with appropriate regard to confidentiality.