Intermediate Care and Frailty Practitioner
5 months ago
The post holder will Undertake clinical assessment and provide treatment for patients within the defined group. Link with existing services to facilitate early discharge from hospital and prevent re-admission. Develop Partnerships and joint working within the wider local health and social care economies. Work collaboratively across organisation boundaries to support the effective and co-ordinated provision of health Clinical Requirements: The post holder will Conduct a comprehensive healthcare assessment, utilising any current information in order to develop an individualised plan of care for patients within a defined group.
**This will include**: Review of health assessment including medical history Physical examination Assessment and review of medication Making referrals for diagnostic tests Functional /cognitive assessment Refer to Social Care partners for assessment. Maintain contemporaneous and accurate clinical records, recording all patient related activity on the clinical systems / databases in accordance with NMC, national legislation and local and national standards Develop, monitor and manage the plan of care in collaboration with the primary health and social care team and others. Application of clinical knowledge about long term conditions Analysis of symptoms and data Identification of risk factors associated with exacerbation of patients condition Recognition of early signs and symptoms of acute illness. Involving patients and carers in the development of the care plan and ensuring that their views and abilities are reflected.
Documentation of progress and continuous reassessment Referral and investigation Set up and actively participates in case review to evaluate the outcomes of care plans including social care needs. Co-ordinate care and treatment to avoid fragmentation, duplication and delay, in the least intensive setting appropriate to the patients needs by: Prioritisation and co-ordination of multiple health needs. Referrals to specialist services. Ensuring effective communication and sharing of appropriate information amongst professionals to avoid conflicting treatments.
Integration across health and social care (inc. voluntary sector and housing). Identifying deficiencies in service provision and address these as appropriate Be aware of and adhere to, the Professional bodies (NMC) Standards and NMC Code of Conduct. (AHPF).
(HCPC). Leadership Requirements The post holder will Lead the process of identifying their caseload through interpretation of the information available on EMIS (clinical IT system) and contribute to the collection of data to monitor outcomes measures Participate in the development of case management across Frailty Services. Provide clinical leadership and mentoring Challenge professional and organisational boundaries to ensure that the Case Management role is focused on meeting the needs of patients, thus promoting continuity of high quality patient centred health and social care. Acts as an advocate and champion for patients in a variety of forums and professional groups and challenges attitudes and behaviours.
Service Development Requirements The post holder will Encourage patient participation in case management The provision of information about disease prevention, progression and outcomes. Ensure that services are accessible to increase patient confidence Empowering the patient to self manage whenever possible. Contribute to the development of role and service redesign in frailty management. Analytical and Information Requirements The postholder will utilise data and data tools (including databases) to produce appropriate monitoring reports on both patient care and service outcomes and produce appropriate communication for patients.
Participate in patient satisfaction reporting to improve patient care. Education and Training Requirements The post holder will Promote formal and informal training to pre and post registration health and social care professionals in relation to integrated working and provide mentorship and teaching to others developing a frailty service Participate in the induction of new staff. Provide education, advice and support to health and social care staff, people with long term conditions and their carers in both community and acute settings. Maintain up to date knowledge and competence in line with professional and service requirements and demonstrate critical thinking, decision making and reflective skills to ensure own professional development.
Communication/Relationship Requirements The post holder will 35. Liaise with patients, community and specialist nursing and other health professionals, GPs, acute colleagues, social care colleagues and the voluntary/charitable and non-NHS sector. Work with patients to: Ensure that their values, beliefs and views are reflected in the case management plan Encourage active participation in case management Ensure that health advice is provided in a professional, accessible and supportive way
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