Visiting & Frailty Practitioner

1 month ago

Redruth, United Kingdom Leatside Health Centre Full time

This is an exciting new role to lead and manage the care of our housebound and care home patients.

We are looking for a skilled and experienced practitioner, with the ability to work autonomously, preferably with primary care experience.

The Practice is known for its pro-active approach within Primary Care and the Primary Care Network, and has a patient population of circa 17,000 patients.

**Purpose of the role**

The post holder will undertake advanced level holistic assessment in order to address complex health care needs by using expert knowledge and clinical judgment to triage, clinically examine, diagnose, initiate interventions and refer appropriately, as an autonomous accountable practitioner.

Whilst directly providing advanced diagnostic and treatment skills, the Visiting & Frailty Practitioner will manage acutely unwell housebound patients within the practice population, liaising with the GPs and community teams who will identify further assessment intervention.

**Key responsibilities**

The following are the core responsibilities of a Visiting & Frailty Practitioner. There may be occasions when there is a requirement to carry out other tasks; this will be dependent on factors such as workload, staffing levels and direction of the Clinical Team or Practice Managers:

- Plan and manage complete episodes of care, working in partnership with others, and delegating and referring as appropriate to optimise health outcomes and resource use, as well as providing direct support to patients
- Undertake home and care home visits (as per the Primary Care Network DES) providing age appropriate physical and psychosocial assessment, interpreting core clinical and diagnostic findings in order to determine a diagnosis and develop an evidence-based plan of care
- To devise effective care plans for each person with specific therapeutic knowledge, recognising the person as an individual, developed in partnership with the person, and where relevant their significant other(s), should be outcome based and ensure appropriate pathways of care and communication via liaison and referral to other agencies as required
- To work in collaboration with a wide range of clinical colleagues including community teams and Social Care professionals, leading and facilitating a person centred focused, co-ordinated case management approach for people who are most vulnerable to, and at high risk of repeat admissions to hospital
- Provide high level anticipatory care through the early identification of disease exacerbation in order to reduce the likelihood of acute illness, risks and prevent hospital admission
- To co-ordinate and support the provision End of Life Care for the patients and their carers/ relatives in collaboration with DN colleagues and specialist care teams as the need arises
- Ensure clinical treatment is safe, effective and conducted within the boundaries of competence, and to acknowledge limitations
- Prescribe and review medication for therapeutic effectiveness, appropriate to patient needs and in accordance with evidence-based practice protocols and formularies
- Work with patients and their carers, in order to support compliance with and adherence to prescribed treatments
- Actively initiate and lead medicine management practice, review prescriptions, planning and adjustment of medicines, facilitating patients understanding to improve concordance
- Undertake telephone triage
- Ensure personal and professional clinical standards are maintained
- Attend the community huddle daily
- Participate in vaccination programmes, vaccinating patients in the Practice, on home visits or in Care Homes
- Ability to work autonomously, asking for help and advice when necessary
- Formally and informally, impart knowledge and skills to colleagues, promoting peer review and best practice within the working environment
- Communicate at all levels within the team, ensuring an effective service is delivered
- Ensure evidence based care is delivered at the highest standard, ensuring delivery of the highest quality patient care
- Work within Practice policies and procedures
- Enhance own performance through continuous professional development, imparting own knowledge and behaviours to meet the needs of the service
- Achieve and demonstrate agreed standards of personal and professional development, in order to meet the needs of the service
- Contribute positively to the effectiveness and efficiency of the team, and work colleagues
- Undertake the collection of pathology specimens, including blood samples, swabs, etc.
- Perform investigatory procedures as requested by colleagues
- Establish and maintain good liaison with other Practices, and the wider system, including secondary care
- Support the clinical team with safeguarding matters, in accordance with local and national policies
- Refer safeguarding concerns, using established safeguarding referral pathways
- Use appropriate infection control procedures
- Be aware of safe storage of e

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